An editorial lamenting poor clinical skills provided grist for discussion among several blogs last week. The controversial article in question was just an opinion piece. But that opinion may be evidence based according to last week’s Archives of Internal Medicine. With the exception of cardiology attendings and fellows, cardiac physical examination across the career spectrum never improved beyond the junior medical student level in this study. Even teaching faculty proved no better than medical students. To me the most telling finding was that participants could correctly differentiate systolic from diastolic sounds only 66% of the time!
The power of physical examination of the heart was shown in this related article which evaluated the third heart sound (S3) as a test. Although not very sensitive, the S3 showed high specificity in predicting elevated BNP, elevated filling pressure and systolic dysfunction.
Findings such as this motivate me to improve my basic clinical skills. With basic knowledge and skill in clinical medicine come power. I’m preaching to myself here. David L. Simel provides editorial commentary on the two studies.
3 comments:
It think we must understand the implicit message when a medical student is shown a physical finding but then a laboratory test is ordered anyways. The student then goes on and often sees the same clinical situation in which exam is *not* done, but the test is still ordered. The message that inevitably comes across is that the lab test is the essential component rather than the clinical exam. Although we can teach its importance until blue in the face, the rewarded activity (in the behavioral sense) is always the diagnostic test...
1. Doctors will not improve at anything simply by well-wishing. The will only improve if they have an economic incentive to do so. Where's that today?
2. Whether technology does a better job is an empirical question. If it does, retire the stethoscopes. What's the big deal?
Here's another aspect of this issue. When is the last time for most physicians when clinical skills were actually observed and critiqued? 3rd year of medical school! From 4th year onward, there is almost no opportunity for observation and feedback of basic examination skills. Any real hands-on, observed training after junior medical student level is directed toward procedural skills. Resident training programs need to make more effort in this respect. Otherwise, there is very little opportunity to improve over time.
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