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Fundamentals of Medicine, Down the Drain

On a routine follow-up visit for bronchitis/pneumonia, I examined a patient by listening to her lungs. The diminished breath sounds on the right side had improved significantly, and after thumping her chest with my fingers, the sounds were resonant and equal. Not only was she feeling much better, her abnormal exam findings had returned to normal as well.

After the examination, the patient remarked that in all her life, no doctor had ever thumped her chest with two fingers. I found her comment surprising, since "percussion" is a basic physical exam technique that all medical students are required to learn and perform. 

This brings up an all-too-common issue these days where doctors are dispensing with time-tested traditional good history taking and thorough physical exams and relying instead on tests. Although there are various reasons for this, the most likely one is due to lack of time. When I was in medical school, I distinctly remember being chided for ordering a test unnecessarily. We were taught that tests were to be ordered only to confirm your clinical diagnosis, if necessary. Unfortunately, tests are routinely ordered today to make a diagnosis in place of good clinical decision making.

Ordering a test should not be undertaken lightly. It should never be ordered, "just in case." Yes, imaging studies and blood tests do occasionally pick up serious conditions, but in most cases, it just leads to more tests and more anxiety for the patient. 

Take, for example, ordering an MRI or CT for headaches. If you order 100 studies, 1-2 will show something significant that explains the symptom. However, in most situations, either the study comes back normal, or comes back with a "suspicious" finding, such as sinus inflammation or polyps. The presence of polyps doesn’t explain the headaches, since many normal people will have sinus inflammation and polyps. The word "polyp" also brings up more worries since we associate it with colon cancer or uterine polyps. Any swelling or growth, even if it’s benign, conjures up the worst case scenario in the patient’s mind. Because of the nature of how studies are interpreted by radiologists, every slight abnormality is pointed out, whether or not it’s clinically relevant. 

MRIs are very sensitive and can pick up findings that have no explanation. Unidentified bright objects or UBOs are frequently described on readings, and despite having no clinical significance in most cases, will also add to the anxiety and fear that patients will experience.

What I’m idealizing is a situation where doctors order tests more judiciously, only after every possible medical explanation has been ruled out. There are certain situations where a test should be ordered urgently, but this makes up only a small fraction of all situations. 

In this era of litigation and stories of missed diagnosis, it’s understandable that doctors may want to order tests prematurely "just in case", and will make some strong justifications for doing so. But in the long run, you end up hurting 99 patients to help one. Not to mention all the extra costs, work hours lost and time worrying over test results. With good follow-up, cooperation between the doctor and the patient, and judicious use of tests, that one patient that actually needs the test will eventually get it done, while saving tests for 99 others.

Ultimately, it all boils down to fundamentals. If we focused on the basic fundamentals of medical practice, then we wouldn’t need as much fancy, high-tech gadgets and testing equipment. It’s like a basketball team where each player tries to win by constantly performing trick shots and spectacular lay-ups. Instead, it takes, time, patience, trust, and cooperation between the doctor and the patient to order a test only as a last resort.