The Price of Your Doctor’s Declining Skills

I recently read that the skills involved in taking a patient’s medical history and performing a physical exam have declined as doctors become increasingly dependent on high-tech diagnostic equipment. Compared to medical education in years past, relatively little emphasis is placed on bedside medicine, a new term for an old concept: getting the necessary information with which to make a sound diagnosis by paying careful attention to the patient’s history, asking the right questions, and performing a competent hands-on examination–all without resorting to the expensive high-tech/low-brain medicine that’s increasingly relied on today.

The medical school course that taught me these essential skills was called Physical Diagnosis (“P-Dog” for short) and it began during my second year. The instructors were all highly seasoned general practitioners and internists, 50 and older (with a few in their 80s), who took a day off from their practices and drove to the medical school to spend time with students. They, as well as their own professors, had all been trained in a pre-tech era, and honestly they were simply wizards at spotting abnormal skin lesions, heart murmurs, neurologic signs, and a thousand other findings needed to make a clear diagnosis.

Our P-Dog textbook was from Great Britain, more than 1000 pages long, and about four inches thick. It was filled with hundreds of diagrams and photos, and also with eponyms. This is the term used when a scientist (in this case, a physician) names a disease, a physical finding, or even an abnormal tissue biopsy after himself/herself. Eponyms were the fodder of teaching rounds, and everyone loved the one-upmanship of P-Dog eponyms.

Listening to a patient’s heart, the attending doc would say, “There’s a Means-Lerman murmur here. What does it sound like and name the disease most associated with it.” (Answer: it’s a scratchy sound that occurs with hyperthyroidism—an overactive thyroid gland.)  For fun, click here to read a Wikipedia list of eponymous physical signs, taking special note of the very first, which incorporates a second eponymous reference (McBurney’s point) in the definition of Aaron sign. We never had to memorize them all, but we did learn why they would occur and where.

Learning bedside skills…or not

The worrisome trend of declining diagnostic skills was the subject of a recent editorial in JAMA entitled “The Road Back to the Bedside.” The author points out something I was completely unaware of–namely, that the one-on-one testing by a seasoned physician examining the skills of a medical student or resident has pretty much been eliminated from medical education. Different training programs had different names for these tests, but here in the Midwest they were called “orals” and you needed to pass them to be eligible to complete your residency or take your Board Exams. Trust me, you’d lie awake in a cold sweat the night before your orals.

The next day you’d meet with one of the professors who escorted you to a patient’s bedside. The professor himself had already read through the patient’s chart, knew the medical history, and had performed his own physical examination. Now it was your turn. He’d leave you there for exactly one hour (woe if you hadn’t finished by the end!) before returning to quiz you about your findings. Today, thousands of patients later, I still remember every detail of my orals patient, an old veteran with aortic valve insufficiency caused by tertiary syphilis.

He also had a smiley face tattooed on the tip of his penis.

Paying the price

The price for the decline in our bedside diagnostic skills turns out to be much higher than realized. A second article, published a month later in JAMA Internal Medicine, was entitled “Worsening Trends in the Management and Treatment of Back Pain.” Keep in mind, though, that back pain trends are merely the tip of the iceberg. Substitute headache, chest pain, or any of a dozen common symptoms and you’ll likely see the same results. They’re all the consequence of trading “brains + low tech” for the more glamorous “no brains + high tech.”

The JAMA piece includes an analysis of 23,918 visits of patients for “spine problems” from 1999 to 2010 and represents a sampling of the estimated 440 million back pain visits nationwide that actually occurred during those years. The trends during that decade are definitely not good:

• Medication recommendations shifted from safer over-the-counter and prescription NSAIDs (declining use) to narcotics (increasing use).
• The number of x rays ordered remained the same (17%), but the number of CT scans and MRIs increased from 7% to 11%.
• The number of referrals for physical therapy remained the same, but the number of referrals to specialists for further treatment (epidural steroids, spinal fusions) increased dramatically for both acute and chronic symptoms, often leading to procedures that frequently yielded disappointing results.

The conclusion is that by relying less on history-taking and physical examinations, primary care physicians are sending their patients off to MRIs and specialists far too quickly. What happens then is that a relatively innocuous finding on an MRI leads to a surgical procedure like an epidural steroid injection or a spinal fusion that gives you at best a 50% chance of relief.

Enter the chiropractors

I was undeniably irritated that chiropractors were simply not mentioned in the “Worsening Trends” article. The authors could have retitled it, “Worsening Trends in the Management and Treatment of Back Pain (Excluding Chiropractors).” Here’s why:

• First, since many chiropractors don’t have immediate access to x rays, CT scans, and MRIs, compared to conventional medical students chiropractic students spend more time learning to physically examine the patient. If we compare apples to apples–the physical exam skills of a chiropractor against those of an orthopedic surgeon–believe me, and I’ve watched them both at work, the chiros would win hands down. (Oh, and if you ever get the opportunity to read your chiropractor’s chart notes, you’ll see they do love their eponyms!)
• Second, because chiropractors aren’t allowed to write prescription drugs, the worrisome trend of increased narcotic prescriptions certainly can’t apply to them. Instead, chiros usually begin with natural anti-inflammatory supplements (like AKBA and Inflavinoid IC, herbal blends) and a muscle relaxant (such as MyoCalm). If these are inadequate, they might suggest an over-the-counter NSAID, like Naproxen, but by that time their chiropractic manipulation has taken effect and if you’ve been doing your prescribed exercises you’ve likely recovered and don’t even feel the need for narcotic drugs like Vicodin.
• Third, chiropractors don’t refer many patients for CT scans and MRIs. Also, because they’re universally skeptical about the alleged benefits of epidural injections and spinal fusions, they work diligently to get a patient well enough so that surgery can be avoided.

What these two articles convey is the combined damage caused by the decline in clinical skills along with unrealistic reliance on high-tech gadgetry.

Some time ago, remarking to an orthopedic friend of mine (who doesn’t do back surgery) about the rapid rise in the number of back surgical procedures, I asked him what exactly the criteria were for resorting to surgery.

Blessed with a wicked sense of humor, he answered “These days, I’m beginning to think the standards are pretty low. First, does the patient have a back? Second, can the patient lie down on an operating table?”

Be well,
David Edelberg, MD