muscular tubing, and the stress of this high-pressure system can cause these weak spots to balloon outward, forming a pulsating bulge in the abdomen. When the balloon gets large enough, the muscle wall becomes dangerously thin and it’s at risk for bursting. The excruciating pain and the restless movement were classic for a tear in the now delicate muscle wall, and the huge pulsating mass clinched the diagnosis. Three quarters of all patients who suffer this dire event die either on the operating table or on their way there.
The vascular surgeons were paged and the patient was taken to the OR, stopping only briefly at the CT scanner to verify the diagnosis. Defying the odds, Mr. Killian survived the surgery, his life saved by a simple touch.
As compelling as any individual case may be, in medicine, if you wantproof you need studies. And McGee has spent his career investigating and tabulating the accuracy of individual components of that endangered art, the physical exam. His results have managed to anger folks on both sides of the debate. Some well-known, frequently taught parts of the physical exam have turned out to be virtually worthless—listening to the lungs will rarely help a physician decide if a patient has pneumonia. Others, when done well, have shown themselves to be as solid and reliable as the tests we use to confirm our diagnoses. In the hands of experts, a cardiac exam can identify problems in the valves of the heart almost as well as the echocardiogram. It’s essential to know how well each of these individual tests performs.
But this research still leaves the big question unanswered: is there any evidence that this old-fashioned practice really makes a difference in how patients do? There is surprisingly little research on this. Several now classic studies done in the 1960s and 1970s tried to assess which tools are most useful in helping doctors make a diagnosis. In these studies the most important tool was the simplest—doctors were able to correctly diagnose patients’ illnesses in most cases just by talking. The patient’s story contained the diagnostic tip-off up to 70 percent of the time. Doctors are told repeatedly in medical school to listen to patients and they will tell you what they have. These studies prove the wisdom of this advice.
But what about the physical exam? In these same studies, when you looked at just those patients whose story didn’t provide the answer, the physical exam led to the right diagnosis about half the time. High-tech testing showed the way in the remaining cases.
Of course, testing has changed a lot since those studies were done. A more recent study, done by Brendan Reilly, a head of clinical medicine at Weill Cornell Medical Center, looked at this question in a different way. Reilly was asked by one of the residents he teaches how important the physical exam was in making a diagnosis. Reilly searched the medical literature for an answer. When he couldn’t find a good answer, he designed his own study.
In a teaching service like his, patients are seen first by the internal medicine residents and then are examined and evaluated separately by the attending physician. The residents and the attending swap the informationthey collected independently to figure out a diagnosis and care plan. Reilly reviewed the charts of all the patients he had admitted to the hospital with his team over the previous six weeks, looking for any case where something he found on the physical exam had changed the diagnosis and the treatment of patients under his team’s care.
The findings were pretty impressive. A careful physical exam changed the patient’s diagnosis and treatment in twenty-six out of one hundred cases—one in four patients. And in almost half of these cases, had Reilly not discovered the correct diagnosis on exam, it would not have been found by “reasonable testing”—that is, testing that would have been ordered if these physical findings had not been
The vascular surgeons were paged and the patient was taken to the OR, stopping only briefly at the CT scanner to verify the diagnosis. Defying the odds, Mr. Killian survived the surgery, his life saved by a simple touch.
As compelling as any individual case may be, in medicine, if you wantproof you need studies. And McGee has spent his career investigating and tabulating the accuracy of individual components of that endangered art, the physical exam. His results have managed to anger folks on both sides of the debate. Some well-known, frequently taught parts of the physical exam have turned out to be virtually worthless—listening to the lungs will rarely help a physician decide if a patient has pneumonia. Others, when done well, have shown themselves to be as solid and reliable as the tests we use to confirm our diagnoses. In the hands of experts, a cardiac exam can identify problems in the valves of the heart almost as well as the echocardiogram. It’s essential to know how well each of these individual tests performs.
But this research still leaves the big question unanswered: is there any evidence that this old-fashioned practice really makes a difference in how patients do? There is surprisingly little research on this. Several now classic studies done in the 1960s and 1970s tried to assess which tools are most useful in helping doctors make a diagnosis. In these studies the most important tool was the simplest—doctors were able to correctly diagnose patients’ illnesses in most cases just by talking. The patient’s story contained the diagnostic tip-off up to 70 percent of the time. Doctors are told repeatedly in medical school to listen to patients and they will tell you what they have. These studies prove the wisdom of this advice.
But what about the physical exam? In these same studies, when you looked at just those patients whose story didn’t provide the answer, the physical exam led to the right diagnosis about half the time. High-tech testing showed the way in the remaining cases.
Of course, testing has changed a lot since those studies were done. A more recent study, done by Brendan Reilly, a head of clinical medicine at Weill Cornell Medical Center, looked at this question in a different way. Reilly was asked by one of the residents he teaches how important the physical exam was in making a diagnosis. Reilly searched the medical literature for an answer. When he couldn’t find a good answer, he designed his own study.
In a teaching service like his, patients are seen first by the internal medicine residents and then are examined and evaluated separately by the attending physician. The residents and the attending swap the informationthey collected independently to figure out a diagnosis and care plan. Reilly reviewed the charts of all the patients he had admitted to the hospital with his team over the previous six weeks, looking for any case where something he found on the physical exam had changed the diagnosis and the treatment of patients under his team’s care.
The findings were pretty impressive. A careful physical exam changed the patient’s diagnosis and treatment in twenty-six out of one hundred cases—one in four patients. And in almost half of these cases, had Reilly not discovered the correct diagnosis on exam, it would not have been found by “reasonable testing”—that is, testing that would have been ordered if these physical findings had not been
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