[tweetmeme source=”Healthmessaging” only_single=false]We have all been there. It often starts with some kind of recurring pain or dull ache. We don’t know what’s causing the pain or ache. During the light of day we tell ourselves that it is nothing. But at 3:00am when the pain wakes you… worry sets in – maybe I have cancer, heart disease or some other life ending ailment. The next day make an appointment to see your doctor.
Ok. Now you are sitting in the Exam Room explaining this scenario to your doctor. Based upon your previous experience, what’s the first thing your doctor would do?
- Order a battery of lab tests and schedule a follow up appointment
- Put you in a patient gown and give you a thorough physical examination, including asking you detailed questions about your complaint, before ordering any tests.
If you answered A you have a lot of company. A recent post on KevinMD.com by Robert Centor, MD reminded me of yet another disturbing trend in the doctor-patient interaction. The post entitled “Many doctors order tests rather than do a history and physical ” talks about how physicians today rely more on technology for diagnosing patients than their own "hands on" diagnostic skills, e.g. a good patient history and physical exam.
Prior to the technology revolution in medicine over the last 20 years, physician training taught doctors how to diagnose patients using with a comprehensive history and physical exam. More physicians today are practicing “test-centered medicine rather than patient-centered medicine.” Medical schools focus on teaching doctors to “click as many buttons on the computer order set as we possibly can in order to cover every life-threatening diagnosis.” The problem is that medicine is still an imperfect science and technology is not a good substitute for an experienced, hands-on diagnostician.
The result of this move to “test-centered” medicine include: 1) more unnecessary tests are ordered, 2) patients are exposed to unnecessary risks (radiation, anxiety, etc.) and 3) health care costs go up.
Get Your Physician To Listen Or….Find A Physician That Knows How To Listen
Sir William Osler (1849-1919), considered the “most influential physician in history,” believed that the best diagnosticians were those that listened to their patients. The following quote attributed to Osler says it best – “Listen to the patient – he (or she) is telling you the diagnosis.”
So the next time you are sitting on the exam table provide a clear, before your doctor can interrupt you, present an organized history of your complaint. Ask your doctor to examine you before referring you out for x-rays or lab tests. If you doctor can make the case for tests after your doctor has heard you out…fine. This way you can be more likely of getting the correct diagnosis.
Sources:
The Fading Art Of The Physical Exam. R. Knox, NPR September 20, 2010.
http://www.npr.org/templates/story/story.php?storyId=129931999#commentBlock
DeMaria, A. Wither the Cardiac Physical Examination? Journal of the American College of Cardiology. Vol. 48, No. 10, 2006.
Mind The Gap 
Recently had the same experience with a patient who went to the ED and they tried to order $5000 worth of tests before he was seen or examined. Our Medical Schools are failing to teach students the value of a good H&P and soon given their dependance on EMR’s to gice them all the information they need, I suspect they will be unable to take a history or perform a detailed exam
“So the next time you are sitting on the exam table provide a clear, before your doctor can interrupt you, present an organized history of your complaint”
Unfortunately most patients don’t find this easy to do.
Fortunately there is technology that can help: http://www.medicalhistory.com
RE: Sir W Osler, I thought you might like this article I wrote recently:
http://3gdoctor.wordpress.com/2010/11/23/what-if-sir-william-osler-had-tweeted/
As a physician and sometime patient, I am appalled by the loss of the art of taking a good history and performing a complete (or at the very least appropriate to the problem) physical exam. Add that to the rush to order tests/scans/procedures that are often unnecessary, always costly and sometimes risky and you have bad medicine. My advice to patients whose doctors order tests before taking a history or doing an exam is to find another doctor. There are still some excellent, caring physicians out there.
Thanks so much for your comments!
I agree. Very nicely written.
The good news is that while MD physicians have forgotten their basics, alternative medicine practitioners excel in these areas ! This is one reason they have become so popular !
Dr Aniruddha Malpani, MD
Medical Director
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Helping patients to talk to doctors !
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Excellent point Dr. Malpani!
Steve Wilkins
A simple question I ask junior doctors, nurses and family physicians to define “Inflammation”. This help me to learn more about the doctors. I was asked this simple question by one of the best doctors, I have ever worked with in Hammersmith Hospital in 1980s. I will publish the answer you should expect depending on the response or comments:
These are some of the definitions I hear, but non are right and this is one of the reason some doctors fumble when a patient ask a simple question they are unable to answer and so result in failed consultation, abuse antibiotic and wasted cost on investigations.
(1) Part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants.
(2) Inflammation is a process to remove the injurious stimuli and to initiate the healing process.
(3) Inflammation is synonym means infection
(4) Inflammation is a stereotyped response, and therefore it is considered as a mechanism of innate immunity, as compared to adaptive immunity, which is specific for each pathogen.
(5) Without inflammation, wounds and infections would never heal.
Some take hours to explain the pathological process but none have so far given me the right definition and so is interesting.