The value of teaching the History and Physical Examination

Students learn many things during their time in medical school. Some things that they learn are soon forgotten (think: the Kreb's cycle). But other things stay with them forever. I can still remember learning how to ask about thyroid symptoms from one of my family medicine mentors. I still use the same words when I ask patients about thyroid symptoms.

Many schools start to teach about taking a history from a patient at the very beginning of medical school. These courses are often called an Introduction to Clinical Medicine.  There are many techniques used to teach students to do an appropriate history and physical examination, but students really start to hone this skill when they complete their clinical clerkships in the third year. The more experience that a student gets in taking a history, the better they get at this skill.

So, an article (1) in JAMA Internal Medicine (the Journal of the American Medical Association's specialty journal for Internal Medicine) caught my eye. In this study, the authors prospectively evaluated patients that were admitted from the emergency room to an academic hospitalist service of Internists. Each patient was interviewed and examined by an experienced senior resident. The patients received a full history and physical examination, and the resident reviewed laboratory tests and xrays done in the emergency room. The resident was then forced to put her nickel down. She recorded her most likely diagnosis and identified the things that were the most helpful in making the diagnosis.

The patients’ were also evaluated by a “senior” clinician, someone with at least twenty years of experience. The senior clinician was a hospitalist who had no knowledge of the senior resident’s diagnosis. The senior resident spent more time (ave 40 minutes per patient) than the senior hospitalist (ave 25 minutes). In this study, 80 percent of the patients admitted were given the correct diagnosis at admission. I think that is really high! 90 percent of the correctly diagnosed patients only received a history, physical examination, and some basic tests.  A few CT scans of the head in the ED, but most did not get anything more than a chest xray or an electrocardiogram.

The senior resident and the senior clinician missed the diagnosis completely on ten percent of the patients but that is consistent with or even lower than other studies of diagnosis. The author wrote, “Our results do not mean that sophisticated studies need not be used after admission, but they do suggest that their choice should be guided by the clinical data on presentation.” That should be a duh, but it is worth repeating. Many studies are ordered by reflex. They are coming into the orthopedic clinic they need an xray of the joint or they are coming in to the cardiologist so they need an electrocardiogram.  It is worse in the hospital. This study supports that a good physical examination and a thorough history are still very sensitive tests. Maybe more sensitive than the CT scan that I am about to order.

Two other quotes that I thought were memorable. From the Editor (of JAMA Internal Medicine) “The (study) by Paley et al reminds us of the value of lower-tech ways of making a diagnosis of patients seen in the emergency department (ED), as technology increases in availability and complexity and because ED health professionals now routinely order imaging tests, not uncommonly without even examining patients.”  The other was from an invited commentary, who said (possibly without actually knowing what he was talking about) that auscultation of the heart was less effective than echocardiography.

So, keep teaching the physical examination and history skills. Your students need them!

References

(1)   Paley L, et al. Utility of Clinical Examination in the Diagnosis of Emergency Department Patients Admitted to the Department of Medicine of an Academic Hospital.  Arch Intern Med  2011;171(15):1393-1400.