Thursday, August 18, 2011
History and physical the best way to diagnose patients
Four out of five doctors agree that they don't need scans to make the right diagnosis.
It's an old-fashioned concept frequently discussed among ACP members, but the history and physical combined with basic tests is way more important to diagnosis than ordering scans and advanced tests. A recent research letter in the Archives of Internal Medicine makes the case.
In the letter, Israeli researchers described a prospective study of 442 consecutive patients admitted from the emergency department in 53 days.
A senior resident examined all patients within 24 hours of admission (mean=14), including a history, physical, and review of ancillary test findings done at the emergency department, such as blood and urine tests, electrocardiography, and chest radiography. The resident also reviewed additional tests such as troponin, C-reactive protein, and international normalized ratio, as well as computed tomography or ultrasonography. Finally, medical charts from previous admissions and all medications and vital signs were reviewed.
The senior resident then determined a main diagnosis and indentified what helped her reach it. Her diagnosis was sealed. Hospital physicians, either hospitalists or medical educators with more than 20 years of experience, repeated the process (mean exam time was less than 25 minutes), and they also sealed their diagnoses. At least one month after discharge, the senior resident verified the patient's final diagnosis and called the patient's primary physician.
The senior resident was correct in 354 of 442 diagnoses (80.1%), while the hospital physicians were correct in 373 patients (84.4%). They made identical correct diagnoses in 327 cases (73.9%). Both were wrong in 42 patients (9.5%) (P=.04).
For the resident and the hospital physicians, patient history was the key element in making the diagnosis. The physicians could make the correct diagnosis on history alone in about 20% of all diagnoses, or in combination with the physical in another 40%. Basic tests with or without the physical examination were key to the correct diagnosis in one-third of cases.
While the exam or basic tests alone were very seldom helpful, the physical examination doubled the diagnostic power of the history (19.5% to 39.0%). Imaging, mainly head computed tomographies, were infrequently used in the emergency department and added little to making the correct diagnoses.
"We found that more than 80% of newly admitted internal medicine patients could be correctly diagnosed on admission and that basic clinical skills remain a powerful tool, sufficient for achieving an accurate diagnosis in most cases," the researchers wrote. 90% of all correct diagnoses were accomplished on presentation through a combination of the history, physical and basic tests. This combination correctly diagnosed three out of four admitted patients.
"Our results do not mean that sophisticated studies need not be used after admission, but they do suggest that their choice should be guided by the clinical data on presentation," the researchers concluded.
Labels: diagnosis, health care cost, medical education, patient care
posted by Ryan DuBosar at
7:00 AM
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Members of the American College of Physicians contribute posts from their own sites to ACP Internist and ACP Hospitalist. Contributors include:
Albert
Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the
University of California, Los Angeles School of Medicine, where he
also did his internal medicine training. Certified by the American
Board of Internal Medicine, Dr. Fuchs spent three years as a
full-time faculty member at UCLA School of Medicine before opening
his private practice in Beverly Hills in 2000.
Zackary
Berger
Zackary Berger, MD, ACP Member, is a primary care
doctor and general internist in the Division of General Internal
Medicine at Johns Hopkins. His research interests include
doctor-patient communication, bioethics, and systematic reviews.
CasesBlog
Ves
Dimov, MD, ACP Member, is an allergist/immunologist and Assistant
Professor of Medicine and Pediatrics at the University of Chicago,
where he evaluates and treats both pediatric and adult patients.
David
Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally
renowned authority on nutrition, weight management, and the
prevention of chronic disease, and an internationally recognized
leader in integrative medicine and patient-centered care.
db's
Medical Rants
Robert M. Centor, MD, FACP,
contributes short essays contemplating medicine and the health care
system.
DrDialogue
Juliet
K. Mavromatis, MD, FACP, provides a conversation about health topics
for patients and health professionals.
Dr.
Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal
medicine for more than a decade and is an Associate Professor of
Medicine at an academic medical center on the East Coast. His time is
split between teaching medical students and residents, and caring for
patients.
Everything
Health
Toni Brayer, MD, FACP, blogs about the rapid
changes in science, medicine, health and healing in the 21st century.
FutureDocs
Vineet
Arora, MD, FACP, is Associate Program Director for the Internal
Medicine Residency and Assistant Dean of Scholarship & Discovery
at the Pritzker School of Medicine for the University of Chicago. Her
education and research focus is on resident duty hours, patient
handoffs, medical professionalism, and quality of hospital care. She
is also an academic hospitalist.
Glass
Hospital
John H. Schumann, MD, FACP, provides
transparency on the workings of medical practice and the complexities
of hospital care, illuminates the emotional and cognitive aspects of
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Gut
Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist
at the University of North Carolina School of Medicine, and the
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specializes in diseases of the esophagus, with a strong interest in
the diagnosis and treatment of patients who have difficult-to-manage
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pain.
I'm
dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic
hospitalist with an interest in basic and clinical science and
education, with interests in noninvasive monitoring and diagnostic
testing using novel bedside imaging modalities, diagnostic reasoning,
medical informatics, new medical education modalities, pre-code/code
management, palliative care, patient-physician communication, quality
improvement, and quantitative biomedical imaging.
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Professor
William Hersh, MD, FACP, Professor and Chair,
Department of Medical Informatics & Clinical Epidemiology, Oregon
Health & Science University, posts his thoughts on various topics
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Just
Oncology
Richard Just, MD, ACP Member, has 36 years in
clinical practice of hematology and medical oncology. His blog is a
joint publication with Gregg Masters, MPH.
KevinMD
Kevin
Pho, MD, ACP Member, offers one of the Web's definitive sites for
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MD
Whistleblower
Michael Kirsch, MD, FACP, addresses
the joys and challenges of medical practice, including controversies
in the doctor-patient relationship, medical ethics and measuring
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Lessons
Elaine Schattner, MD, ACP Member, shares
her ideas on education, ethics in medicine, health care news and
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Rob Lamberts, MD, ACP Member, a med-peds and general
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of an Internist
Justin Penn, MD, ACP Associate Member,
attended medical school at the University of Washington School of
Medicine and trained in internal medicine at the University of
Rochester, where he is serving as Chief Resident.
Prescriptions
David
M. Sack, MD, FACP, practices general gastroenterology at a small
community hospital in Connecticut. His blog is a series of musings on
medicine, medical care, the health care system and medical ethics, in
no particular order.
Reflections
of a Grady Doctor
Kimberly Manning, MD, FACP,
reflects on the personal side of being a doctor in a community
hospital in Atlanta.
Technology
in (Medical) Education
Neil Mehta, MBBS, MS, FACP,
is interested in use of technology in education, social media and
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personal information and knowledge management.
White
Coat Underground
Peter A. Lipson, MD, ACP Member, is a
practicing internist and teaching physician in Southeast Michigan.
The blog, which has been around in various forms since 2007, offers
musings on the intersection of science, medicine, and culture.
Other blogs of note:
American
Journal of Medicine
Also known as the Green
Journal, the American Journal of Medicine publishes original clinical
articles of interest to physicians in internal medicine and its
subspecialities, both in academia and community-based practice.
Clinical
Correlations
A collaborative medical blog started
by Neil Shapiro, MD, ACP Member, associate program director at New
York University Medical Center's internal medicine residency program.
Faculty, residents and students contribute case studies, mystery
quizzes, news, commentary and more.
Interact
MD
Michael Benjamin, MD, ACP member, doesn't accept
industry money so he can create an independent, clinician-reviewed
space on the Internet for physicians to report and comment on the
medical news of the day.
PLoS
Blog
The Public Library of Science's open access
materials include a blog.
White
Coat Rants
One of the most popular anonymous blogs
written by an emergency room physician.
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