If physicians and doctors in training were trained better in the physical exam, could that translate into health care dollars saved?
I’ve written about the Physical Exam and how it’s often at odds against newer technologies in medicine. In today’s world, where labwork, xrays and CT scans are so readily available, many say the physical exam is dead and just a relic of tradition.
Case Review: This thought was provoked by a patient I saw in the emergency department recently. A 76 year old lady presented with a distended abdomen that had been growing the last 5 days. On history, she also developed shortness of breath on exertion, orthopnea, PND, all classic signs for congestive heart failure. Looking through her records, she had been admitted previously for an episode of CHF two years ago secondary to ischemic heart disease. On physical examination she had an audible S3 heart sound, distended JVP and leg edema. Chest Xray showed bilateral pleural effusions and vascular redistribution typical of CHF. This was a lady who’s classic findings were pointing to to a diagnosis of exacerbation of her CHF.
Question: for this patient, should we order a BNP? A BNP is a good marker that is highly sensitive for CHF. It costs about $25 to run. [www.ccjm.org/content/70/4/333.full.pdf]
I had recently been trying to go through the JAMA Rational Clinical Exam Series and had just finished “Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure?” According to the article, in a patient with clear history and physical suggestive of CHF, doing a BNP was not recommended as it would not change management.
I didnt’ want to order a BNP as I knew it would come back positive anyway, but in the age of “defensive medicine” the ER doc ordered a BNP, along with a complete panel of bloodwork that was probably unnecessary. The results came back as expected with an elevated BNP of 680 and the rest of the labwork unremarkable.
Futuredocsblog, an internist from the University of Chicago, writes about certain things doctors could do to help reduce health care costs. Listening to the patient, doing a proper physical exam, thinking about indications for a test and knowing the costs of the tests that are ordered.
As doctors, we are entrusted to be good stewards of the finite resources available. Perhaps I’m just young and naive, and all it takes is one lawsuit to change my opinion. But right now, I believe good history taking and physical exams can help reduce the number of unnecessary tests and therapeutics.
What do you think? Is the physical exam dead? Can a good history and physical exam hold up against the available labwork and technology of today?
Update (Mar 2013) – an excellent journal article on the Utility of the Clinical Examination at JAMA Network
This isn’t answering your question, but it’s a thought I have related to your article. In terms of making cost effective decisions, I don’t think we can, or perhaps even should, put the onus on the individual to make optimal, cost-effective decisions. The more I think about it, the more this is an issue that needs to be addressed at a system wide level. The only way to motivate health care professionals to make optimal economic decisions is to design the system in a way that encourages them to do so. With the current design of the system, it is in neither the physician’s (nor the patient’s) best interest to do so. And yes this is most definitely a problem.
Hey Josh, good to hear from you. How would you design a system that encourages physicians to make cost-effective decisions? I think there is room from improvement at the top (policy level) and at the bottom (doctor-patient). Obviously we should try not to factor costs into our decision making, we should always be acting in the patient’s best interest. But I think training doctors to be more conscientious of resources is a easy and tangible step to take. It won’t be enough, but it’s something that we can start with.
The problem is that there is disconnect between what’s taught in the classroom and what is taught at the bedside. At UofT, and I’m sure at many other medical schools as well, we are given a few lectures on quality of care, patient safety, and cost-effective decision making. However, translating these into practice as a medical student is not very easy. Every supervisor/preceptor’s position on these issues is different (and very often non-existent), along with varying positions by unit, department, and then across the hospital itself. As an example from your post, I would guess most medical students would not want to give the impression of undermining their supervisor by questioning their decision making. By questioning I don’t mean just asking “oh, why did you order this test?” but actually going all the way to challenge their thought process – I don’t think we can reasonably expect clerks, who are being evaluated, to challenge their preceptors on this sort of issue.
In order to train doctors to be cognizant of these issues, they need to be trained in an environment where cost-effectiveness is being taken seriously. If we leave the system the way it is and we just ask preceptors to try and teach these issues, it’s not going to happen, plain and simple. They have no motivation to do so. And a few lectures in pre-clerkship have limited utility when students go out and see something completely different in practice.
So what do we need to do? We need to change the way the system is designed, thereby changing current physician practices, which will trickle down into the way future physicians are trained. How should we design the system? I am of the opinion that funding should be tied to accountability at the hospital-wide level. Consider two similarly sized hospitals, with similar staff/facilities, and serving the same population. However, one has a readmission rate for congestive heart failure patients of 20%, and the other has a readmission rate for CHF patients of 5%. There is clearly something different in hospital system design that is leading to better quality of care in the 2nd hopsital over the 1st, and this ultimately translates into a difference in quality and efficiency of health care being provided. There needs to be incentives in place to encourage Hospital A to get where Hospital B is. That may mean rewarding hospital B and penalizing hospital A.
This is of course a simplified example, but the idea is that hospitals and health systems need to be held accountable for the way they deliver care and to be motivated to continuously find ways to deliver better care at a lower cost. And we need to change incentives and funding to motivate them to do so.
Once we change culture and practice, inevitably, we will change the way we train future physicians.
I agree with you completely, I guess I was looking for specific examples for change. Funding and incentives is a good idea, but I guess it’s so hard for clinicians to really feel that impact when it seems like all the decisions are made from above.
After being on the wards, and I’m sure you have noticed too, there’s so much our health care could improve in. Patient safety, effective handovers, coordinating care, quality discharges and adequate follow-up. It’s a systemic problem.
Glad you got to work at the CICC this summer, if I’m ever in Toronto in the future, I’ll be sure to check out what they do!
I started clerkship with a perspective on the health care system (w/ regards to patient safety and quality of are) largely driven by my experience with CICC this past summer. I fully expected to see these challenges on the wards, such as the ones you mentioned. And of course I did. What I also realized, however, was how difficult it is to achieve optimal care. I see physicians and other health care professionals working tirelessly, and I begin to see why system failures occur. Asking for individuals to pursue perfection in their craft as health care professionals is asking for a lot. It’s ideal, but it’s terribly difficult and demanding. I do think we can leverage technology to deal with a lot of it, but that in itself is going to be quite challenging.
I agree – communication and understanding between management and front line clinicians is most certainly a challenge. And I’m certain most front-line clinicians would be very much against tying accountability to funding (because well, it’s not in their best interests). The fascinating thing about health care systems is that it’s often not the lack of effective solutions that is the problem – it’s the lack of communication, collaboration and overall lack of will. There are so many competing interests in health systems, thereby hindering change, which is what makes it both fascinating and frustrating at the same time.
I actually don’t agree very much at all. Certainly there are systematic issues at play, yet the habits and practice of individual physicians is enormously important and – frankly – it seems rather an easy way out to absolve individuals of not thinking through their work or providing substandard or sloppy care.
It is actually very simple to think through a set of admission orders and ask yourself “how will investigation x change the management?”. If you don’t have an answer for that or – worse – believe it won’t change it all, you are either not understanding what you’re doing or willfully wasting resources and (sometimes) exposing the patient to unjustified increased risk.
I have also never encountered a staff preceptor or resident who would ever be offended or put off by my suggesting a different course of management. It is not “questioning” to offer an opinion, or even to wonder whether something is appropriate. As a clerk you don’t have to be and aren’t expected to be right – but taking an active part in the discussion shows interest and is always welcome. On those occasions where a preceptor might not be interested one way or another, you’ll find out pretty quickly and take the appropriate cues. But overall I think your first paragraph is poor advice.
I further disagree with your hypothetical about the “system” aspect of differing outcomes between hospitals. Certainly the “system” plays a role, but a “system” is not black box. While hospital B might have an NP working on the Cardiology floor full-time to better manage patient care, hospital A might not have the funding for such a position – penalizing it is hardly the solution!! For that matter, hospital A might simply end up seeing even more complex patients, or this outcome rate might fluctuate a fair bit depending on the year or season. If you want to figure out what at a system level works and works better and what doesn’t, you need to look at specifics – i.e. what makes hospital A and B different. Messing around with simplistic “incentive-based” schemes is the sort of nonsense that so-called “market-based” reforms will lead us. To take the hypothetical a bit further, suppose hospital A loses funding and closes beds, forcing hospital B to open more beds. At the same time, perhaps A is less overcrowded then before and provides better care, while B is regularly overwhelmed with patients waiting in the corridors – after all, we’ll refer to the “best” centre! Care suffers at B as a result. Your solution seems pretty naive at best.
The point here is that we need to find solutions to motivate health care professionals and organizations to work towards better quality care at a more sustainable cost. No one is saying that the habits of individual practitioners is not important – you are suggesting I don’t think so, which is not true at all. Obviously I agree that trying to make optimal decisions in patient care is something everyone should aim for. My point is that there’s very limited utility in just saying “oh, physicians should give good care, and if they don’t, well, that’s bad”. That’s just an observation, a statement, but it provide no utility in guiding us towards a solution. If it was as “simple” as that, we wouldn’t see all of the errors and inefficiencies that persist in health care delivery.
It’s quite a leap of faith to just hope everyone will do the right thing. Not only are we only human, but we’re human with varying values and level of dedication. It’s the same thing with patient safety – of course we’d hope everyone would be vigilant and careful, but we know very well people are not acting optimally. We should work towards designing a system that encourages better, thoughtful care, especially at an individual level. In no way does my argument go against good individual decision making – trying to encourage it is precisely what I’m arguing in favour of.
I don’t disagree at all that it’s fine to discuss alternative options in management. In fact, I have no idea why you think we are disagreeing on that issue. All I said was that it would probably difficult for a clerk to challenge a preceptor on issues such as resource allocation and cost-effective care depending on their interest level.
On a final note, your address of my example was based on a misinterpretation of my example. I said consider two hospitals that are essentially equal, and perhaps my bad for not explicitly pointing out what I mean by equal, but sure let’s assume identical funding, facilities and patient populations. My whole point is that if there are two nearly identical hospitals with identical funding and populations, but one is providing higher quality of care at a lower cost than another, then this theoretically implies one hospital is likely doing something better than the other, and that the other hospital has theoretically proven room to improve. There is no need to make up random hypotheticals for why this scenario might not be true – it’s a theoretical exercise, no?
I’m not saying I have some perfect solution to some of our most pressing problems in health care funding and delivery. I do think there is a lot of merit to the idea of tying funding to accountability. But if you’re going to tell me I’m wrong, then I’d appreciate some fundamentally sound rational, and not just being told a concept is ‘naive’. I would hope as future health care professionals we can have a discussion more useful than that.
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