[ editorial * editorial
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WHERE ARE THE HISTORY AND THE PHYSICAL? Georges Bordage, MD, PhD
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In clinical practice, the history and physical examination are being superseded by laboratory tests and biomedical technology. The author discusses the importance of the clinical examination as the basis for clinical reasoning and of direct observation of students at the patients' bedside in order to assess their diagnostic reasoning. Greater attention to the clinical examination would lead not only to improved clinical skills but also to more cost-effective uise of ancillary investigations and, moreover, to a better understanding of the patient by the physician.
few years ago I and some colleagues spent half a kday each week, for 4 weeks, conducting direct observation of junior residents in internal medicine to provide them with formative feedback on their historytaking and physical-examination skills. At the end of the last feedback session, one of the residents asked, with a somewhat dumbfounded look, why we were paying so much attention to these skills. He went on to add that when he goes "down there," meaning the emergency department, the name of the game is which laboratory tests to order, not the details of the history and physical examination. Where have the history and the physical A
examination gone?
Since this incident, I have found, to my dismay, that many residents and medical students share that perception. The shift in emphasis from clinical to high-tech ancillary medicine can be viewed as a sign of technologic progress; for example, the availability of highly selective biochemical tests and detailed imaging are welcome advances. However, the situation is troubling, partly because of the great concern for cost containment and health care reorganization in our times, but more fundamentally because the very basis of the profession is being challenged. Clinical reasoning and acumen are being traded for technology. This is not a new debate. Similar
Dans la pratique m6dicale, l'anamnese et l'examen physique du malade semblent ceder le pas aux examens de laboratoire et a la technologie bio-medicale. L'importance de l'examen clinique comme base du raisonnement clinique est discut6e ainsi que limportance d'observer directement les etudiants au lit du malade afin d'6valuer leur raisonnement diagnostique. Le fait de porter davantage attention 'a 1examen clinique aura pour cons6quence non seulement l'amrlioration des habilet6s cliniques du medecin mais aussi un choix plux judicieux d'examens complementaires et surtout, une meilleure comprehension du malade par le m6decin.
voiced at the turn of the century with the advent of blood counts.' I am assuming that hasty test ordering is synonymous with letting the numbers in the laboratory results tell the clinician what could be wrong with the patient. This is especially troubling when the numbers are almost always assumed to be correct and there is little or no discussion about the sensitivity and specificity of tests. In the contrasting approach, the clinician uncovers the problem from the findings of a focused and well-taken history and a well-conducted physical examination. Two are at issues clinical acumen and cost-effectiveness stake, as the following two studies have illustrated. Schmitt, Kushner and Wiener' found that the primary diagnosis could be predicted from the history for 74% of patients admitted with dyspnea in internal medicine. More recently, Wiener estimated that the accuracy of diagnostic prediction could be as high as 90% to 95% when the findings from the physical examination are added to the history (Dr. Stanley L. Wiener, Naperville, Ill.: personal communication, 1994). Macdessi and Oates, concluded that the increased use of diagnostic imaging, compared with clinical examination, did not lead to earlier diagnosis or better management of pyloric stenosis. Although imaging proved important in identiconcerns were
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Dr. Bordage is a professor in the Department ofMedical Education, College of Medicine, University of Illinois at Chicago. Chicago, Ill.
Reprint requests to: Dr. Georges Bordage, Department of Medical Education (M/C 591), University of Illinois at Chicago, 808 S Wood St., Chicago IL 60612-7309; fax 312 413-2048;
[email protected]
