{"id":6180,"date":"2013-09-29T18:29:34","date_gmt":"2013-09-29T23:29:34","guid":{"rendered":"http:\/\/wholehealthchicago.com\/?p=5842"},"modified":"2022-03-21T14:59:07","modified_gmt":"2022-03-21T19:59:07","slug":"the-price-of-your-doctors-declining-skills","status":"publish","type":"post","link":"https:\/\/wholehealthchicago.com\/blog\/2013\/09\/29\/the-price-of-your-doctors-declining-skills","title":{"rendered":"The Price of Your Doctor\u2019s Declining Skills"},"content":{"rendered":"\n

I recently read that the skills involved in taking a patient\u2019s 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\u2019s history, asking the right questions, and performing a competent hands-on examination–all without resorting to the expensive high-tech\/low-brain medicine that\u2019s increasingly relied on today.<\/p>\n\n\n\n

The medical school course that taught me these essential skills was called Physical Diagnosis (\u201cP-Dog\u201d 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.<\/p>\n\n\n\n

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.<\/p>\n\n\n\n

Listening to a patient\u2019s heart, the attending doc would say, \u201cThere\u2019s a Means-Lerman murmur here. What does it sound like and name the disease most associated with it.\u201d (Answer: it\u2019s a scratchy sound that occurs with hyperthyroidism\u2014an overactive thyroid gland.)  For fun, click here<\/a> 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.<\/p>\n\n\n\n

Learning bedside skills\u2026or not<\/b><\/h3>\n\n\n\n

The worrisome trend of declining diagnostic skills was the subject of a recent editorial in JAMA<\/i> entitled \u201cThe Road Back to the Bedside<\/a>.\u201d 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 \u201corals\u201d and you needed to pass them to be eligible to complete your residency or take your Board Exams. Trust me, you\u2019d lie awake in a cold sweat the night before your orals.<\/p>\n\n\n\n

The next day you\u2019d meet with one of the professors who escorted you to a patient\u2019s bedside. The professor himself had already read through the patient\u2019s chart, knew the medical history, and had performed his own physical examination. Now it was your turn. He\u2019d leave you there for exactly one hour (woe if you hadn\u2019t 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.<\/p>\n\n\n\n

He also had a smiley face tattooed on the tip of his penis.<\/p>\n\n\n\n

Paying the price<\/b><\/h3>\n\n\n\n

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<\/i>, was entitled \u201cWorsening Trends in the Management and Treatment of Back Pain<\/a>.\u201d 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\u2019ll likely see the same results. They\u2019re all the consequence of trading \u201cbrains + low tech\u201d for the more glamorous \u201cno brains + high tech.\u201d<\/p>\n\n\n\n

The JAMA<\/i> piece includes an analysis of 23,918 visits of patients for \u201cspine problems\u201d 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:<\/p>\n\n\n\n