A Vanishing Art
Here's a Story I read nor long ago in the New England Journal of Medicine:
A man in his fifties comes to an emergency room with excruciating chest
pain. A medical student is told to check the blood pressure in both arms.
He checks the closer arm and calls Out the blood pressure. He moves to the
other side of the patient bur is unable to find a blood pressure. Worried that
this is due to his inexperience rather than a true physical finding, he says
nothing. No one noticæs. Overnight the patient is rushed to the operating
room for repair of a tear in the aorta, the vessel that carries blood out of the
heart to the rest of the body. He dies on the operating table.
A difference in blood pressure between arms or the loss of blood pressure
in one arm is strong evidence of this kind of tear, known as a dissecting
aortic aneurysm. The student's failure to speak up about his inability to read
the blood pressure on one side of the patient's body prevented the discovery
of this evidence.
Here's another story—this one from a colleague of mine:
A middle-aged woman comes to the hospital With a fever and difficulty
breathing. Shed been treated for pneumonia a week earlier. In the hospi
tal she's started on powerful intravenous antibiotics. The following day she
complains of in her back and weakness in her legs. She has a history of
chronic back pain and her doctors give her painkillers. They do not examine
her. When her fever spikes and her white blood cell count soars, the team
gets a CT scan Of the chest, looking for something in her lungs that would
account for a worsening infection. What they find instead is an abscess on
her spinal cord. She is rushed to surgery.
Had the team examined her, they would have found a loss of sensation
and reflexes, which would have alerted them to the presence Of the spinal
cord lesion.
This Story was recently presented at Grand Rounds, a high-profile weekly
lecture for physicians, at Yale:
A man has a heart attack and is rushed to the hospital, where the blocked
coronary artery is reopened. In the ICU, his blood pressure begins to drop;
he complains of feeling cold and nauseated. The doctors Order intravenous
fluids to bring up his dangerously low blood pressure. They do not examine
him. When, after several hours, his blood pressure continues to drop, the
him. When, after several hours, his blood pressure continues to drop, the
cardiologist is called and she rushes back. When she examines him she sees
that his heart is beating rapidly but is barely audible. The veins in his neck
are distended and throbbing. She immediately recognizes these as signs that
the man has bled into the sac around his heart—a condition known as tamponade. It is a well-known complication Of (he procedure shed done just
hours before. She rushes him back to the OR and begins draining the blood,
which by now completely fills the sac, preventing the heart from beating.
Despite her efforts, the man dies on the table. Had the doctors in the
examined the patient, rather than paying attention only to the monitors
tracking his vital signs, they would have been able to diagnose this potentially reversible complication.
This is another kind Of Story doctors tell one another in hospital hallways
and stairwells—cautionary tales from the pages of our best journals, cases
presented at the weekly Grand Rounds Or Morbidity and Mortality Conferences, where medical errors are traditionally discussed. These are the
tragic stories Of patients Who worsen and sometimes die because clues that
could have and should have been picked up With a simple physical examination were overlooked or ignored. We repeat them to one another as lessons learned—a prayer and talisman. We tell them with sympathy because
we fear that any one of us might have been that doctor, that resident, that
medical student.
These anecdotes reveal a truth already accepted by most doctors: the
physical exam—once our most reliable tool in understanding and diagnosing a sick patient—is dead.
wasn't a sudden or unanticipated death. The death of the physical
exam has been regularly and carefully discussed and documented in hospital hallways and auditoriums and in the pages Of medical journals for over
twenty years. Editorials and essays have posed
once unthinkable questions
like: "Physical diagnosis in the 1990s: Art or artifact?" or "Has medicine
Outgrown physical diagnosis?" and "Must doctors examine patients?" And
finally in 2006, the flat announcement Of the long-anticipated death was
valued part Of being a doctor.
finally in 2006, the flat announcement Of the long-anticipated death was
carried in the pages Of the New Journal of Medicine. In "The De-
mise of the Physical Exam," Sandeep Jauhar tells the story of that inexperienced medical
student couldn't find a blood pressure on a man With chest pain and an aortic dissection Who dies as a result. It is the tasty opening anecdote in an Obituary—not for the patient but for this once
valued part Of being a doctor.
The physical exam was once the centerpiece of diagnosis. The patient's
story and a careful examination would usually suggest a diagnosis, and then
tests, when available, could be used to confirm the finding. These days,
when confronted with a sick patient, doctors often skip the exam altogether,
instead shunting the patient directly to diagnostic imaging or the lab, where
doctors can cast a wide net in search of something they might have found
more quickly had they but looked. Sometimes a cursory physical examination-
is attempted but With expectations as physicians, instead, eagerly
await results Of a test they hope Will tell them the diagnosis.
Many doctors and researchers are troubled by this shift. They complain
about the overuse of expensive high-tech tests and decry' the decline of the
skills needed to conduct an effective physical exam. Yet despite this uneasi-
ness, doctors and even patients increasingly prefer What they perceive to be
the certainty Of high-technology testing to a low-tech, hands-on examina-
tion by a physician.
Measuring the loss of Skills
In the early 1 Salvatore Mangione, a physician and researcher at Thomas
Jefferson University Medical Center in Philadelphia, began studying how
well doctors were able to recognize and interpret common findings on one
fundamental component of the physical exam, the examination of the heart.
He rested 250 medical students, residents, and postgraduate fellows specializing in cardiology from nine different training programs. The investigation
Was straightforward enough: students and doctors Were given an hour to
listen to twelve important and Common heart sounds and answer questions
about what they heard.
The results were stunning and controversial. A majority Of the medical
students could identify only two out of the twelve sounds correctly. The
other ten were recognized by only a handful of the students. Surprisingly,
the residents did no better. Despite their additional years of experience
and training, they were able to correctly identify only the same two examples. Perhaps most disturbing Of all, most Of the doctors holding a post residency fellowship in cardiology were unable to identify six out of the twelve sounds.
In a similar test on lung sounds, Mangione again found that students and
residents failed to identify many Of the most common and most important
sounds of the body. If letter grades were being handed out, all but a handful
Of these participants would have gotten a big fat F.
In the years since Mangione first published his studies, editorials and lec-
curers have bemoaned this loss of skills and warned that if action isn't taken
to remedy the problem, we'll end up with teachers who know no more than their students
Sort of Blind leading the blind.
Here's a Story I read nor long ago in the New England Journal of Medicine:
A man in his fifties comes to an emergency room with excruciating chest
pain. A medical student is told to check the blood pressure in both arms.
He checks the closer arm and calls Out the blood pressure. He moves to the
other side of the patient bur is unable to find a blood pressure. Worried that
this is due to his inexperience rather than a true physical finding, he says
nothing. No one noticæs. Overnight the patient is rushed to the operating
room for repair of a tear in the aorta, the vessel that carries blood out of the
heart to the rest of the body. He dies on the operating table.
A difference in blood pressure between arms or the loss of blood pressure
in one arm is strong evidence of this kind of tear, known as a dissecting
aortic aneurysm. The student's failure to speak up about his inability to read
the blood pressure on one side of the patient's body prevented the discovery
of this evidence.
Here's another story—this one from a colleague of mine:
A middle-aged woman comes to the hospital With a fever and difficulty
breathing. Shed been treated for pneumonia a week earlier. In the hospi
tal she's started on powerful intravenous antibiotics. The following day she
complains of in her back and weakness in her legs. She has a history of
chronic back pain and her doctors give her painkillers. They do not examine
her. When her fever spikes and her white blood cell count soars, the team
gets a CT scan Of the chest, looking for something in her lungs that would
account for a worsening infection. What they find instead is an abscess on
her spinal cord. She is rushed to surgery.
Had the team examined her, they would have found a loss of sensation
and reflexes, which would have alerted them to the presence Of the spinal
cord lesion.
This Story was recently presented at Grand Rounds, a high-profile weekly
lecture for physicians, at Yale:
A man has a heart attack and is rushed to the hospital, where the blocked
coronary artery is reopened. In the ICU, his blood pressure begins to drop;
he complains of feeling cold and nauseated. The doctors Order intravenous
fluids to bring up his dangerously low blood pressure. They do not examine
him. When, after several hours, his blood pressure continues to drop, the
him. When, after several hours, his blood pressure continues to drop, the
cardiologist is called and she rushes back. When she examines him she sees
that his heart is beating rapidly but is barely audible. The veins in his neck
are distended and throbbing. She immediately recognizes these as signs that
the man has bled into the sac around his heart—a condition known as tamponade. It is a well-known complication Of (he procedure shed done just
hours before. She rushes him back to the OR and begins draining the blood,
which by now completely fills the sac, preventing the heart from beating.
Despite her efforts, the man dies on the table. Had the doctors in the
examined the patient, rather than paying attention only to the monitors
tracking his vital signs, they would have been able to diagnose this potentially reversible complication.
This is another kind Of Story doctors tell one another in hospital hallways
and stairwells—cautionary tales from the pages of our best journals, cases
presented at the weekly Grand Rounds Or Morbidity and Mortality Conferences, where medical errors are traditionally discussed. These are the
tragic stories Of patients Who worsen and sometimes die because clues that
could have and should have been picked up With a simple physical examination were overlooked or ignored. We repeat them to one another as lessons learned—a prayer and talisman. We tell them with sympathy because
we fear that any one of us might have been that doctor, that resident, that
medical student.
These anecdotes reveal a truth already accepted by most doctors: the
physical exam—once our most reliable tool in understanding and diagnosing a sick patient—is dead.
wasn't a sudden or unanticipated death. The death of the physical
exam has been regularly and carefully discussed and documented in hospital hallways and auditoriums and in the pages Of medical journals for over
twenty years. Editorials and essays have posed
once unthinkable questions
like: "Physical diagnosis in the 1990s: Art or artifact?" or "Has medicine
Outgrown physical diagnosis?" and "Must doctors examine patients?" And
finally in 2006, the flat announcement Of the long-anticipated death was
valued part Of being a doctor.
finally in 2006, the flat announcement Of the long-anticipated death was
carried in the pages Of the New Journal of Medicine. In "The De-
mise of the Physical Exam," Sandeep Jauhar tells the story of that inexperienced medical
student couldn't find a blood pressure on a man With chest pain and an aortic dissection Who dies as a result. It is the tasty opening anecdote in an Obituary—not for the patient but for this once
valued part Of being a doctor.
The physical exam was once the centerpiece of diagnosis. The patient's
story and a careful examination would usually suggest a diagnosis, and then
tests, when available, could be used to confirm the finding. These days,
when confronted with a sick patient, doctors often skip the exam altogether,
instead shunting the patient directly to diagnostic imaging or the lab, where
doctors can cast a wide net in search of something they might have found
more quickly had they but looked. Sometimes a cursory physical examination-
is attempted but With expectations as physicians, instead, eagerly
await results Of a test they hope Will tell them the diagnosis.
Many doctors and researchers are troubled by this shift. They complain
about the overuse of expensive high-tech tests and decry' the decline of the
skills needed to conduct an effective physical exam. Yet despite this uneasi-
ness, doctors and even patients increasingly prefer What they perceive to be
the certainty Of high-technology testing to a low-tech, hands-on examina-
tion by a physician.
Measuring the loss of Skills
In the early 1 Salvatore Mangione, a physician and researcher at Thomas
Jefferson University Medical Center in Philadelphia, began studying how
well doctors were able to recognize and interpret common findings on one
fundamental component of the physical exam, the examination of the heart.
He rested 250 medical students, residents, and postgraduate fellows specializing in cardiology from nine different training programs. The investigation
Was straightforward enough: students and doctors Were given an hour to
listen to twelve important and Common heart sounds and answer questions
about what they heard.
The results were stunning and controversial. A majority Of the medical
students could identify only two out of the twelve sounds correctly. The
other ten were recognized by only a handful of the students. Surprisingly,
the residents did no better. Despite their additional years of experience
and training, they were able to correctly identify only the same two examples. Perhaps most disturbing Of all, most Of the doctors holding a post residency fellowship in cardiology were unable to identify six out of the twelve sounds.
In a similar test on lung sounds, Mangione again found that students and
residents failed to identify many Of the most common and most important
sounds of the body. If letter grades were being handed out, all but a handful
Of these participants would have gotten a big fat F.
In the years since Mangione first published his studies, editorials and lec-
curers have bemoaned this loss of skills and warned that if action isn't taken
to remedy the problem, we'll end up with teachers who know no more than their students
Sort of Blind leading the blind.
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