Key points are not available for this paper at this time.
Several years ago I had the unusual good fortune to find a first edition of Cecil's Textbook of Medicine in a small used-book shop. The vast majority of the book details intricate, complicated, and subtle maneuvers designed to increase diagnostic acumen. I read with awe page after page of arcane components of the physical exam, many of which I had never heard of and certainly had not seen employed in modern medical practice. I kept saying to myself, “I would never do that, I'd just order XYZ test.” In the preface to their 1981 masterpiece Bedside Diagnostic Exam, 4th Edition, Drs. DeGowin and DeGowin discuss the rise of a third diagnostic approach to complement (or in some cases to supersede) the history and physical exam. They call this “diagnostic mode: laboratory data.” My impulse to order an “XYZ test” rather than to follow the diagnostic procedures outlined in Cecil's Textbook reflect this continuing trend in medicine toward the increasing use of technology. Still, as a practitioner and teacher of physical examination and diagnosis, I, like many others, am troubled at times by this trend. Increasingly, the price we pay for technology is a diminution of our ability to touch a patient, to make a human connection and assure the patient that a physical diagnosis has been achieved. How do we balance the patient's need for our touch with the advances in diagnostic accuracy technology has brought to medicine? IS THE PHYSICAL EXAM RELIABLE? The findings of physical examinations have always been open to interpretation. As early as 1966, Smyllie et al. observed poor interrater reliability in the interpretation of the pulmonary examination.2 More recently, Wipf et al. found diagnostic maneuvers to be of little utility in diagnosing pneumonia by physical examination. They found no single maneuver to be highly sensitive or specific. At best, special testing had only a modest ability to predict the presence of pneumonia, with again, poor interrater reliability even among acknowledged experts.3 In a study of reliability of physical signs in the examination of the chest, Spiteri found whispered pectoriloquy to be totally unreliable and vocal fremitus only possibly reliable.4 The physical examination skills we have cherished and passed on as dogma to our students were derived from the anecdotal evidence of our ancestors in medicine. No actual experiments or studies were ever performed that might indicate a predictive value to whispered pectoriloquy. It was assumed that since Osler said it was so, it therefore must be so. The anecdotal evidence for the reliability and validity of these tests was never questioned in a scientific manner. In light of modern imaging techniques, must we continue to teach maneuvers that have become quaint historical relics of a bygone era? Continually, my students tell me “my preceptor says that's a useless test,” specifically, with regard to what are now considered outdated special tests of the pulmonary system. I then lose credibility with my students. I become an ivorytower academic with little understanding of the real world. With the continued rise in the use of diagnostic technology, many physical examination skills are being lost. Should they be taught at all? With the availability of diagnostic imaging, are we doing our students a disservice by going over physical examination skills that have traditionally been a part of the medical examination, skills that may no longer be germane? Is it worthwhile teaching respiratory excursions, diaphragmatic excursion, succussion splash, whispered pectoriloquy, egophony, bronchophony and vocal fremitus other than as historical relics of a less sophisticated medical era? Further, what is the threshold for ordering a radiograph or CT of the chest? When does a clinician discard special testing and move to an imaging technique? If we are to embrace the technologic advances of medical science (as I think we should), how do we maintain a proper balance of high tech with high touch? I have chosen to focus on the pulmonary examination, but there are many components of the complete examination that are giving way to advanced imaging and lab techniques. Why waste time with tuning-fork hearing tests when much more sophisticated instruments for measuring hearing exist? Why spend time on such gross tests as visual fields by confrontation, when, in a vision booth, using modern techniques, precise measurements of field defects are made easily and quickly? Does anyone really rely on percussion of the cardiac borders to determine cardiomegaly? Does anyone actually take 15 to 20 minutes to perform the puddle test? A perfect example is the use of Patrick's test in making a diagnosis of sacroiliac joint syndrome (SIJS). A recent paper in the Archives of Physical Medicine and Rehabilitation found that, at best, this test simply included SIJS as part of the differential diagnosis, rather than confirmed it. Confirmation would come from imaging.5 Why, then, do we teach these tests and techniques? The traditional argument has been that in a rural, isolated area, advanced technology may not be available and the standard is a thorough physical examination. But even this argument no longer holds water. The courts, under pressure from plaintiff attorneys, have increasingly held a national standard to be the rule of medical practice. Even in a rural, isolated practice venue, a clinician might not be able to get a CT immediately, but one could be obtained within 24 hours. If a CT were needed emergently, a rotary or fixed-wing air ambulance could be summoned rapidly. Another argument is that of cost reduction. Webber and Rinne tests are much cheaper than advanced hearing testing. But again, the albeit controversial but prevailing national standard of care obviates tuningfork tests. WHERE DO WE GO FROM HERE? If special tests continue to assume lesser importance in medical diagnosis, it is imperative that we improve the teaching of active listening skills, making the medical history more important than it has ever been. We must also strongly encourage students to believe patients' stories and physical examination findings, even in the face of a negative imaging or other test result. A CT might give a false-negative reading, in spite of an enlarged pulsatile abdominal aorta found on physical examination. Clearly, more research needs to be done regarding the reliability, validity, and efficiency of diagnostic maneuvers in comparison with imaging and laboratory techniques. Still, the hallmark of our profession from the beginning has been an outstanding, thorough physical examination. In Human, All Too Human, Nietzsche made a remarkable statement: “It is the mark of a higher culture to value the little truths, obtained by rigorous method, rather than the dazzling tales spun by metaphysical ages and men who blind us and make us happy.”6 Finding the right balance between high tech and high touch will continue to be a challenge for medical practitioners well into the next millennium. Communicating it to the next generation of practitioners may be even more difficult.
Ivy Todd (Sat,) studied this question.