Wednesday, July 15, 2009

What Happened to Physician Diagnosis?

In recent posts, I’ve addressed the high cost of health care often associated with lesser quality when overuse or misuse of treatment and procedures are undertaken and when more emphasis is placed on treatment instead of prevention.

Clearly, another reason for these costly and often ineffective practices is that some older physicians may not be using the important tools associated with physical diagnosis, and some younger physicians may not be learning them.

When I was in medical school over 40 years ago, much time was spent on learning and then relying on four processes to make a diagnosis of our patient:
1. Inspection – Look at the patient and tell me what you see and what you think it indicates. Is the skin pale? It could indicate anemia. Yellow? Liver disease. Puffy? Hyperthyroidism.
2. Palpation (putting your hands on the body) – Do you feel breast mass, thyroid nodule, hernia, abdominal mass or abdominal aneurysm?
3. Percussion (beating on the chest & abdomen with a two-finger/drum stick technique) – Have you identified a solid lung lesion, or air or fluid in the pleural or abdominal cavity?
4. Auscultation (listening with a stethoscope to the heart, lung and bowel sounds) – Do you hear pneumonia, mitral valve disease, aortic regurgitation, or an obstructed, non-functioning bowel?

In addition, smell and a good history can be added to the four tools described above as inexpensive but often reliable adjuncts to reach the right diagnosis. I quickly learned that you can smell a pseudomonas infection on a burn patient, and that a person with acute appendicitis is never hungry.

These are important tools that cost little or nothing, but could focus the diagnosis with fewer lab and radiological tests. Unfortunately, however, the first line of approach by many providers as they begin the diagnostic journey is to start with an MRI or the CAT scan. And because we have far too many of these machines in the U.S., they, too, are overused.

I worry that the skills of physical diagnosis are rapidly being forgotten, and I worry more that if we do not enhance their uses in the future, the costs of health care may never decline.

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