Fwd: [IMPROVEDX] BP measurements and Stethoscope use

Kuhn, Gloria gkuhn at MED.WAYNE.EDU
Wed Sep 18 13:52:20 UTC 2013


I think Manoj makes some very good points and I am glad he highlighted the portion about the physical exam (especially true of the history) driving the tests we order.  I would also add that serial exams are very powerful especially in abdominal complaints.
Regarding the stethoscope there are more powerful models but most physicians don't purchase them relying on the classic models and at some point they may indeed be replaced with technologically superior models.  But a quiet room, taking time to carefully listen, improves the sensitivity of auscultation.  The English do it very well.
What I believe will be replaced (when possible)  with something better is the CT exam due to unacceptable rates of cancer as a result of multiple CT exams over the lifetime of the patient (I realize that this is a stretch).  But consider ultrasound which is rapid, can be performed at the bedside, and has no side effects, or MRI which does not deliver radiation and in some cases is more sensitive than CT.
Gloria


From: robert bell [mailto:rmsbell at ESEDONA.NET]
Sent: Tuesday, September 17, 2013 8:52 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [IMPROVEDX] Fwd: [IMPROVEDX] BP measurements and Stethoscope use

"...we get rid of tests that are more accurate than previously." That should read less accurate than current ones.

Begin forwarded message:


From: robert bell <rmsbell at ESEDONA.NET<mailto:rmsbell at ESEDONA.NET>>
Date: September 17, 2013 5:27:16 PM MST
To: "Mittal, Manoj K" <MITTAL at email.chop.edu<mailto:MITTAL at email.chop.edu>>
Subject: Re: [IMPROVEDX] BP measurements and Stethoscope use

Agree Manoj,

The point I would like to stress is that as we move forward with medicine we get rid of tests that are more accurate than previously. The stethoscope, for ALL who use it is, I believe, remarkably inaccurate, but I do not have the studies/figures to support that hypothesis (why we need them).

The stethoscope I believe needs to be replaced by other technologies. And in time, I believe, that it will.

The best,

Rob
On Sep 17, 2013, at 4:06 PM, Mittal, Manoj K wrote:


Hi Robert,

Thanks for sharing your story and insight.

I want to reiterate the importance of good history and exam.

When Gloria wrote, "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."

I think the highlighted part (I did it) is as important as the relationship part.

Take the example of a child presenting to an ED with abdominal pain. Just this presenting complaint gives us a pre-test probability of about 5-10% for appendicitis.
Recently we conducted a study re appendicitis, where clinicians enrolled patients that they suspected as having appy. to the study (based on history and exam). 40% of the enrolled patients were confirmed to have appy, which translates to a likelihood ratio of about 5.8 for physician gestalt. We need to realize that the odds of appy have gone up but not enough to take such a patient to the OR; this is where the role of advanced imaging comes in. Positive abdominal CT in such a setting (with a sensitivity of 94% and specificity of 95%) will have a post-test probability (or positive predictive value) of 93% which is considered acceptable.
But a positive CT for every pt. coming with abd. pain will only have a post-test probability of only 50%.

Just an illustration of Bayesian statistics. We have to work at finding as many pointers to increase (or decrease) our diagnostic probability, whether they come from history, exam, lab tests, imaging, or any other field, while at the same time trying to keep our biases in check! A tall order, but there is unlikely to be a panacea/one-shot test.

Regards,
Manoj

Manoj K. Mittal, MD, MRCP (UK), FAAP
Attending Physician
Co-Chair, QI and Patient Safety Committee
Director, Emergency Department Extended Care Unit (EDECU)
Division of Emergency Medicine
The Children's Hospital of Philadelphia
Associate Professor of Clinical Pediatrics
Perelman School of Medicine, University of Pennsylvania
Philadelphia, PA

________________________________
From: Robert Bell [rmsbell at ESEDONA.NET]
Sent: Tuesday, September 17, 2013 11:57 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] BP measurements and Stethoscope use
Nice comments Gloria,

Let's guess that the stethoscope in the average hands is just 50% accurate. Would a computer generated differential diagnosis list from the history alone, or even something else like a hand held sonography unit (if providing additional information to the stethoscope) with or without a stethoscope get to a correct diagnosis quicker?

I take the point about patient relationships, but does a better hands-on patient relationship with the touch of a stethoscope elicit more accurate information or just provide more biases and problems and lead one down the garden path of confusion?

The question would seem to be do we need a different model from the standard history, physical exam, differential, studies, diagnosis, and treatment, used for centuries, that embraces computers and other technological advances for improvements in diagnosis to occur? And I appreciate that we are moving in that direction.

Rob Bell

Only good studies will give you the answer.

Rob

Sent from my iPad

On Sep 17, 2013, at 4:45 AM, "Kuhn, Gloria" <gkuhn at MED.WAYNE.EDU<mailto: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<mailto:ezamir at UNIMELB.EDU.AU>]
Sent: Monday, September 16, 2013 7:17 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<mailto:rmsbell at ESEDONA.NET>]
Sent: Monday, 16 September 2013 2:55 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<mailto: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<http://www.peggyRCC.wordpress.com/>

On Fri, Sep 13, 2013 at 1:17 PM, robert bell <rmsbell at esedona.net<mailto: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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