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