BP measurements and Stethoscope use

Joyce Muni joyce.muni1860 at GMAIL.COM
Tue Sep 17 18:16:52 UTC 2013


Your impassioned reply was well appreciated. We are clinicians first, and
hands on can not be substituted for! I took a friend to an internist. The
patent had a cough. The doctor introduced himself, and promptly sat down to
write for an antibiotic and CAT scan of the chest. I looked at him and
said, aren't you going to examine him?
WHOA!!
JTMUNI, MD


On Tue, Sep 17, 2013 at 1:13 PM, Joyce Muni <joyce.muni1860 at gmail.com>wrote:

> Thank you so much. Excelllent.
>
>
> On Tue, Sep 17, 2013 at 6:45 AM, Kuhn, Gloria <gkuhn at med.wayne.edu> wrote:
>
>>  Dear Colleagues,
>> It is true that the physical exam is not as sensitive or specific as many
>> imaging studies.  But is it something that we need to keep doing to
>> determine what studies to order and  as part of the way in which we
>> establish a relationship with a patient.  If we never touch, never listen,
>> never palpate, and only order lab and imaging studies can the patient
>> perceive us as anything but a technician and moreover one that appears to
>> be very uninvolved with our patients.
>>
>>  I think we need a balance, the careful history and then the careful
>> exam, and the explanation of why we need to order the tests because they
>> are indeed more sensitive then the physical exam and we don't want to miss
>> something.
>>
>>  A colleague sent me the link to the following discussion of the
>> "ritual" of the physical exam by Dr. Verghese.  You may have already seen
>> it and if so you already know his philosophy regarding the physical exam.
>>
>>  Finally, as I follow these discussions I can't help but think, if the
>> goal is zero errors, we are doomed to failure.
>> In researching medical errors I came across a number of articles which
>> looked at errors during autopsies.  the one that made an impression me was
>> by Kirch.  Admittedly old but it looked at this over a prolonged period of
>> time.  The message was that technology had not decreased errors but changed
>> the ones made.
>>
>>  I am NOT advocating for not testing, for not being careful to look at
>> the tests we order and informing the patients of results.  I am suggesting
>> that we do the history and physical exam being aware of the inaccuracies
>> and pitfalls.  And that we be honest with patients about what we do and
>> don't know as a result of our exam and our tests.
>>
>>  I am sure that Bob feels a sense of betrayal and anger over the delayed
>> diagnosis.  I think all of us would.  I know I would.  But medicine is not
>> perfect and we are not infallible.  What we can be is careful, honest,  and
>> caring and not defensive as we so often are when we can't solve the
>> patient's problem.  What we can do is try to study clinical decision making
>> and make it as good a tool as possible.  Can I remember 52 biases, always
>> adding more as they are published?  NO, most of the time I am not aware of
>> my biases as they are often unconscious.
>>
>>  But I can rethink my diagnosis when things don't fit or the patient
>> doesn't improve.  I can have the courage to be honest with patients.  I can
>> read about types of thinking.  I can attend this conference and read and
>> learn from all of you.  I can continue to read medical literature.  I can
>> do those things.  Those are things I can consciously control and I will.
>> Gloria Kuhn
>>
>>   Kirch W, Schafii C. Misdiagnosis at a university hospital in 4 medical
>> eras. Medicine. 1996; 75:29–40.
>>
>>   http://www.ted.com/talks/abraham_verghese_a_doctor_s_touch.html
>>
>>
>>  ------------------------------
>> *From:* Ehud Zamir [ezamir at UNIMELB.EDU.AU]
>> *Sent:* Monday, September 16, 2013 7:17 PM
>>
>> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>> *Subject:* Re: [IMPROVEDX] BP measurements and Stethoscope use
>>
>>   Dear Rob
>> Do you know whether, in your wife's case, PE was considered and judged to
>> be unlikely, or simply not considered?
>> Ehud
>>  ------------------------------
>> *From:* robert bell [rmsbell at ESEDONA.NET]
>> *Sent:* Monday, 16 September 2013 2:55 AM
>> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>> *Subject:* Re: [IMPROVEDX] BP measurements and Stethoscope use
>>
>>  My wife was diagnosed with asthma and given bronchodilator for a week
>> or so - turned out to be a pretty severe pulmonary embolus with a Factor V
>> Leidin problem.
>>
>>  Rob
>>  On Sep 14, 2013, at 10:26 PM, Benbassat Jochanan wrote:
>>
>>   OK, the stethoscope has a limited value for the examination of the
>> heart. What about for the examination of the lungs, particularly for the
>> initial evaluation of a patient with acute dyspnea?
>>
>>  Jochanan Benbassat
>>
>>  *From:* Peggy Zuckerman [mailto:peggyzuckerman at GMAIL.COM]
>> *Sent:* Sunday, September 15, 2013 12:43 AM
>> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>> *Subject:* Re: [IMPROVEDX] BP measurements and Stethoscope use
>>
>>
>>   Rob,
>>  If someone invented the stethoscope yesterday, and tried to introduce
>> it to the medical world, advising that one could just "listen" to the
>> varying sounds, and from there, diagnosis with certainty a wide range of
>> diseases and problems, he would be laughed off the block.  When there are
>> more objective ways to measure hearts, which permit comparisons between
>> professionals and institutions, listening with a stethoscope sounds like
>> the equivalent of my touching the child's head with the back of my hand.
>> Tells me something, but not much, and not verifiable.
>>  Peggy Z
>>
>>  www.peggyRCC.wordpress.com
>>
>>
>>  On Fri, Sep 13, 2013 at 1:17 PM, robert bell <rmsbell at esedona.net>
>> wrote:
>>  Dear Bill,
>>
>>   I have often thought that taking blood pressure in the office is one
>> of the worst things that the medical profession does
>>
>>
>>
>>
>>
>>  ------------------------------
>>
>>
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>> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair,
>> Society for Improving Diagnosis in Medicine
>>
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/
>>
>>
>> Save the date: Diagnostic Error in Medicine 2013. September 22-25, 2013
>> in Chicago, IL.
>> http://www.dem2013.org
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>>
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>>
>>
>> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair,
>> Society for Improving Diagnosis in Medicine
>>
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/
>>
>>
>> Save the date: Diagnostic Error in Medicine 2013. September 22-25, 2013
>> in Chicago, IL.
>> http://www.dem2013.org
>>
>>
>> ------------------------------
>>
>>
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>>
>>
>> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair,
>> Society for Improving Diagnosis in Medicine
>>
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/
>>
>>
>> Save the date: Diagnostic Error in Medicine 2013. September 22-25, 2013
>> in Chicago, IL.
>> http://www.dem2013.org
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>>
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>> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair,
>> Society for Improving Diagnosis in Medicine
>>
>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/
>> Save the date: Diagnostic Error in Medicine 2013. September 22-25, 2013
>> in Chicago, IL.
>> http://www.dem2013.org
>>
>
>








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