Patient History, Physicals Are Time Well Spent
I have been practicing medicine for 21 years. I had a private practice for 17 years before beginning a hospitalist program at our local hospital four years ago. I found “Final Exam?” (April 2007, p. 25) very interesting.
Most interesting were Dr. Andrew Bomback’s comments. He might consider that those “retired physicians” are realistic in their critique. Most physicians, if not all trained prior to the mandated 80-hour workweeks, had just as much paperwork and carried pagers. In fact, many worked past the magical 12-hour shift and carried extensive hours into practice from residency. Few had the ancillary support available today. While it is true the physical exam has evolved, it is no less important in these days of technology.
The accurate history and physical exam suggest a differential diagnosis, from which we order tests to confirm or dispute. In the days of my residency training, internists were known to be the physicians who wrote the most orders, and there was a certain ill-found pride in seeing what obscure but pertinent tests one could order. Managed care, for all its problems, has made us focus on efficiency. It is there that the history and physical exam shine. In my opinion, they are paramount for cost-effective management of patients.
A recent example: I was asked to see a 47-year-old patient in the ED last week who presented with dyspnea. The ED physician had done a cursory exam and ordered the initial workup. The [chest X-ray] demonstrated cardiomegaly and pulmonary vascular congestion. The patient’s cardiac enzymes were normal, and his BNP was 82. The ED physician told me the EKG did not demonstrate new ST or T wave changes. A d-dimer was elevated, so he ordered a CT pulmonary angiogram. I arrived to see the patient prior to the patient leaving for CT. The patient had jugular venous distention, his heart tones were muffled, and he had pulsus paradoxicus. As I left the room, the patient went for CT. This was negative for PE but showed a large pericardial effusion. The echo I ordered confirmed the findings of tamponade. The physical exam should have led to the echocardiogram, thus eliminating the need for CT—a significant saving for the patient.
One of the benefits hospitalists offer is time spent with patients, as opposed to private practice physicians coming from their offices to see patients. There is no better time spent for physician and patient than the history and physical.
Al Caccavale, DO, FACOI
Chairman, Board of Trustees
Yavapai Regional Medical Center, Prescott, Ariz.
