ArticlesPhysical examination in the care of medical inpatients: an observational study
Introduction
Concerns about physicians' declining bedside skills have prompted the US National Board of Medical Examiners to propose that, beginning in 2004, physicians-in-training must demonstrate competence in physical examination before they can receive a medical licence. Currently, only about a quarter of US medical schools require their students to pass such tests as a condition of graduation.
However, even if all physicians acquire basic skills in physical examination, will they maintain and improve those skills throughout their professional careers? Very few residency programmes include physical diagnosis in their curricula.1, 2 Specialty board-certification examinations no longer require an oral component with demonstration of bedside skills. Continuing medical education conferences rarely offer opportunities to update skills in hands-on examination. Indeed, the time pressures of modern practice, combined with advances in diagnostic technology, seem to undermine the value of these skills. Is expertise in physical examination still important in clinical medicine?
This question is reminiscent of scepticism in the 1980s about the importance of the autopsy. At that time, declining hospital autopsy rates prompted Goldman and colleagues3, 4 to compare the value of autopsies in periods before and after the availability of new diagnostic imaging technologies. These investigators found that the autopsy's yield remained substantial (major diagnoses unsuspected pre-mortem in 22–25% of patients), undiminished from 1959 through 1985. Their findings energised efforts to revive the autopsy as an essential quality improvement process in hospitals.
Thus, it seems noteworthy that no previously published studies have addressed the clinical importance of physical examination in the care of patients in hospital.
Section snippets
Background
In the week after completing a rotation as an attending physician in a hospital, this author began teaching an introductory physical diagnosis course to second-year medical students. In response to students' questions about the importance of physical examination in the care of inpatients, I searched PubMed for English-language medical published work from 1966 through 2001. Finding no data directly relevant to this question, I reviewed the medical charts of all patients who had been admitted to
Results
100 patients were admitted to my service during the 28-day period. Patients' mean age was 55 years; their median hospital length of stay was 3 days. Patients' principal final diagnoses are listed in table 1. Six patients died in hospital. For 28 patients, various language barriers affected my initial clinical assessment.
Chart review identified 37 patients with possible pivotal findings. The adjudication panel rejected 11 of these because they did not meet all the criteria; the remaining 26
Discussion
These results show that physical examination can have a substantial effect on the care of medical inpatients. About one in every four (26%) patients in the present investigation had pivotal physical findings. In many patients, these findings prompted active collaboration by specialist consultants to perform urgent surgical (or other invasive) procedures. The seven patients with class 1 findings were especially important because diagnostic testing other than physical examination would probably
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