Author Affiliation: Department of Medicine (Emeritus Professor of Medicine), University of California, San Francisco.
The main responsibility of the physician to a patient is to make an accurate diagnosis so that appropriate treatment can be instigated. For centuries the physician had only the history and physical examination as the instruments to use in making a diagnosis of the patient's illness. Gradually, basic laboratory tests were added, and at the beginning of the 20th century, radiography and later electrocardiography were developed. Most patients with symptoms sufficient for them to appear in an emergency department (ED) have a wide variety of illnesses, many of which are readily diagnosed without sophisticated imaging techniques. So how important in arriving at a correct diagnosis are these modern (and expensive) imaging devices for the usual spectrum of diseases seen in the ED?
Over the years there have been many previous studies1- 3 performed on ambulatory patients supporting the major contribution of the history and physical examination in making the correct diagnosis in patients with medical diseases, with laboratory studies important in the minority of cases. The study by Paley et al4 appears to be the first prospective study done on patients sick enough to be admitted to the hospital that convincingly shows that a physician with 4 years' experience in the ED can make a correct diagnosis in the ED 80% and the senior hospitalist 84% of the time, using mainly the history, physical examination, and basic laboratory tests without the use of the modern imaging techniques. The history alone was most valuable approximately 20% of the time, and although the physical examination alone was most valuable less than 1% of the time, when used in conjunction with the history, the physical examination doubled its diagnostic power to almost 40%. Less than 10% of the time both missed the correct diagnosis. Computed tomography was used 12% of the time, mostly for head examination, and ultrasonography, I assume including echocardiography, was used less than 4% of the time.
It would be helpful to know how many hospitalists took part in the study. The more physicians involved, the less likely that we are dealing with exceptionally talented clinicians and the more generalizable the findings become. It would also be helpful if the diagnoses that were made in these 442 patients, as well as the 10% of diagnoses missed by both the ED physician and the hospitalist, would be listed in a table. The high diagnostic accuracy using predominantly the traditional tools of history, physical examination, and basic laboratory tests would be less exciting if the majority of the patients had asthma, upper respiratory tract infections, urinary tract infections, or psychological problems.
Having been an internal medicine resident and cardiology fellow in the 1950s and practiced for the first 12 years in the era before echocardiography, I can attest that our experienced cardiologists could make an accurate diagnosis with these basic diagnostic tools most of the time. In the study by Paley et al,4 only the accuracy of ED diagnosis was evaluated, not the management of the patient. Today, in the patients being evaluated for possible cardiovascular disease, echocardiography would be more often used in arriving at a diagnosis and especially in making management decisions for the patient.
The modern imaging techniques when used appropriately have made the diagnosis of the patient's disease and management more timely and accurate. There is also no doubt that these imaging techniques are overused, both to reassure the physician that a proper diagnosis was made and to act as a defensive measure against a claim of malpractice. Although these imaging tests are generally benign as far as adverse events are concerned, for certain, these techniques increase the cost of medical care significantly. In an era when the medical dollar must be spent wisely since we have reached the bottom of the money barrel for medical care, we physicians must be responsible for using these studies only when they add significantly to the diagnosis or aid in an important way to management decisions.
When I first read the article by Paley et al,4 I mentally recognized that “I knew it all along.” As a teacher of medical students, house staff, and cardiology fellows I have become increasingly aware that there has been ever decreasing time spent teaching the basic skills of history taking and physical examination, especially cardiac auscultation.5- 6 As a cardiologist, I see less attention paid to these basic skills and especially to auscultation, considered by many no loss since echocardiography has been developed. It is impossible to argue against a technique that is more accurate than auscultation in diagnosing cardiac diseases and helpful in designing an approach to treatment. However, in an era when amazing imaging can determine a diagnosis and practice guidelines for management of most diseases are available, the physician, as opposed to the technician, adds only 2 things that are indispensable in caring for patients: the physician-patient relationship and informed judgments in making therapeutic decisions. The physician-patient relationship is formed at the time of initial contact during the taking of an attentive history and the performance of a careful physical examination. When the time comes to deciding that the patient needs surgery or an expensive or uncomfortable diagnostic study, without the confidence that the physician is knowledgeable and completely involved in their problem, it is likely that the patient will seek other opinions until they find someone they trust.
The study by Paley et al4 is highly supportive of the physician's ability using the classic diagnostic tools including a medical history, the physical examination, and basic laboratory studies to make an accurate diagnosis, reserving the expensive imaging techniques for those patients for whom there is diagnostic confusion or when difficult management decisions must be made. In this way, we can help reduce the cost to the patient without compromising the quality of their care.
Correspondence: Dr Cheitlin, Department of Medicine, University of California, San Francisco, San Francisco General Hospital, 1001 Potrero Ave, Room 5F8, San Francisco, CA 94110 (firstname.lastname@example.org).
Financial Disclosure: None reported.
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