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Ideas and Opinions |

The Bedside Evaluation: Ritual and Reason

Abraham Verghese, MD; Erika Brady, PhD; Cari Costanzo Kapur, PhD; and Ralph I. Horwitz, MD
[+] Article and Author Information

From Stanford University School of Medicine and Stanford University, Stanford, California; Western Kentucky University, Bowling Green, Kentucky; and GlaxoSmithKline, King of Prussia, Pennsylvania.


Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-0676.

Requests for Single Reprints: Abraham Verghese, MD, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, S102, Stanford, CA 94305-5110.

Current Author Addresses: Dr. Verghese: Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, S102, Stanford, CA 94305-5110.

Dr. Brady: Department of Folk Studies and Anthropology, Western Kentucky University, 1906 College Heights Boulevard #61029, Bowling Green, KY 42101-1029.

Dr. Kapur: Department of Anthropology, Stanford University, Sweet Hall, 590 Escondido Mall, Stanford, CA 94305-3023.

Dr. Horwitz: GlaxoSmithKline, 709 Swedeland Road, King of Prussia, PA 19406.

Author Contributions: Conception and design: A. Verghese, E. Brady, C.C. Kapur, R.I. Horwitz.

Analysis and interpretation of the data: A. Verghese, E. Brady, C.C. Kapur, R.I. Horwitz.

Drafting of the article: A. Verghese, E. Brady, C.C. Kapur, R.I. Horwitz.

Critical revision of the article for important intellectual content: A. Verghese, E. Brady, R.I. Horwitz.

Final approval of the article: A. Verghese, E. Brady.

Administrative, technical, or logistic support: A. Verghese.

Collection and assembly of data: A. Verghese, E. Brady, R.I. Horwitz.


Ann Intern Med. 2011;155(8):550-553. doi:10.7326/0003-4819-155-8-201110180-00013
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The bedside evaluation, consisting of the history and physical examination, was once the primary means of diagnosis and clinical monitoring. The recent explosion of imaging and laboratory testing has inverted the diagnostic paradigm. Physicians often bypass the bedside evaluation for immediate testing and therefore encounter an image of the patient before seeing the patient in the flesh. In addition to risking delayed or missed diagnosis of readily recognizable disease, physicians who forgo or circumvent the bedside evaluation risk the loss of an important ritual that can enhance the physician–patient relationship.

Patients expect that some form of bedside evaluation will take place when they visit a physician. When physicians complete this evaluation in an expert manner, it can have a salutary effect. If done poorly or not at all, in contrast, it can undermine the physician–patient relationship. Studies suggest that the context, locale, and quality of the bedside evaluation are associated with neurobiological changes in the patient. Recognizing the importance of the bedside evaluation as a healing ritual and a powerful diagnostic tool when paired with judicious use of technology could be a stimulus for the recovery of an ebbing skill set among physicians.

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Bedside Evaluation: Ritual and Reason
Posted on November 1, 2011
Neil A., Louwrens, MD, FACP, Internal Medicine/Hospitalist/Informaticist
Catholic Healthcare West
Conflict of Interest: None Declared

The article by Verghese titled 'Bedside Evaluation: Ritual and Reason' in the October 18th edition addresses many concerns about our departure from the tried and true thorough bedside clinical evaluation. Could it be that the solution to healthcare overspending is indeed at our fingertips? Who would ever have thought that, in our traditional teaching to 'Look, Listen and Feel' we would find our students one day migrating to only the first of these, albeit in the form of dazzling imaging modalities, and sadly effectively aborting the importance of the latter two?

To employ all our 'faculties' is unavoidably time consuming. However, this article highlights what patients really want: time and touch! It appears that they are after all looking for the 'touchy-feely'. So, how do we take a step back? Or, is it the step forward?

When we renege on 'time', favoring rather haste, erroneously under the guise of efficiency, we provide limitless fodder to the malpractice industry. 'Liability' is truly the spoilt child of a passing era, an unaffordable privilege exponentially inconveniencing far more than it's pitifully few beneficiaries. Yet, this fearful mindset is what overwhelmingly drives everyday clinical care. We are indeed in danger of abandoning the tools of our trade. These tools, when used, and used correctly, will pay remarkable dividends. Perhaps, in the new era of denials for services, the astute clinician, tools in hand, will once again take his seat at the table of relevance, and be front and center in the battle for cost containment. To my skillful colleagues, I offer, an age old reminder: "The answer is in your hands!"

Neil A. Louwrens MD, FACP Catholic Healthcare West Internal Medicine/Hospitalist/Informaticist

Conflict of Interest:

None declared

The Bedside Evaluation: Ritual and Reason
Posted on November 4, 2011
Anthony O., Ogedegbe, MD, General Internist
Weill Cornell Medical College
Conflict of Interest: None Declared

In their October 18, 2011, article, "The Bedside Evaluation: Ritual and Reason," Verghese et al perform an important service in stressing the continued relevance--not to mention elegance and economy--of the physical exam in current medical practice (1). Weary and perhaps even skeptical novice clinicians, in particular, will find both solace and encouragement in the message of this article. The authors offer a number of excellent insights, particularly the recommendation that trainee clinicians not only receive "hands-on" instruction on how to conduct a good physical exam, but that they also be "observed and corrected at the bed-side."

Where Verghese and his colleagues' musings veer off course is in proposing that the physical exam be reconceived as a therapeutic intervention. Common patient refrains, "my doctor never touched me" and "the doctor never laid a hand on me," are deployed as proof of the intrinsic healing properties of a physician's physical exam.

In reality, however, most practicing physicians would interpret these statements differently: less a plea for more physical exam rigmarole per se, and more frustration that not enough time, attention or care was devoted to their problem. Far from insisting on an exam where none may be warranted, such patients really just want to be heard and given the opportunity to ask questions and air residual concerns.

That simple, thoughtful communication--in the absence of physical contact--often has a salutary effect is curious (2); suggesting, perhaps, that a better case could be made for talk, rather than touch, as the key to forging successful therapeutic relationships with patients.

The overly esthetic, or to quote the authors, "romantic," posture on medical practice adopted in this article is also problematic. In the first place, esthetic preferences, because they mostly reside in the "eye of the beholder," can be somewhat arbitrary. They are frequently informed by generational mores or practices that were standard-of-care during formative years of clinical training. Consequently, such items often transfer tepidly from instructor to learner, leaving the former disappointed and the latter bemused.

A more effective way to spur millennial physicians towards more thoughtful clinical practice, particularly with respect to the physical exam, is to provide them with concrete, scientific justifications for parts of the exam you expect them to perform. For example, routine examination of neck veins for jugular venous distention (JVD)--a more than century-old practice--remains standard of care in the initial evaluation of acute congestive heart failure because, given the right level of expertise and clinical context, it is a good indicator of elevated central venous pressure (3). The "clincher," however, with today's trainee clinicians is that JVD, unlike brain naturietic peptide (BNP) and echocardiography at most institutions, can be expertly assessed--without piercing the skin to draw blood--in seconds with nothing more than access to a flash light.

Finally, while "ritualization" (or "routinization") of certain aspects of medical practice is sometimes warranted to uphold basic standards, ritual for ritual's sake--in addition to the condescension it heaps on patients--carries with it the threat of dogma and intellectual stagnation. It is doubtful that the genius that conceived of the stethoscope at a time when the order of the day was to bleed, cup, and purge patients intended to replace one ritual with yet another (1).

References:

(1) Verghese A, Brady E, Kapur C, Horwitz RI. The Bedside Evaluation: Ritual and Reason. Ann Intern Med. 2011;155(8):550-553

(2) Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor- patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. 1994 Jun 27;154(12):1365-70.

(3) Stevenson LW, Perloff JK. The limited reliability of the physical signs for estimating hemodynamics in chronic heart failure. JAMA 1989;261:884-8.

Conflict of Interest:

None declared

Bedside Evaluation Important
Posted on November 4, 2011
Edward J., Volpintesta, MD
Danbury Hospital
Conflict of Interest: None Declared

In an era that has fetishized imaging and laboratory testing, the authors' espousal of the importance of the bedside evaluation has particular importance. (1) Even if one is not adept in the diagnostic skills that good bedside examination requires, there is much to be learned just by sitting down and talking to the patient and encouraging him/her to describe their symptoms and their personal histories. Talking and listening establishes a connection with patients that is a two-way affair. First, of course the doctors gets knowledge of when a symptom started, how long it has lasted, and any other accompanying information that along with the physical exam will help to establish a diagnosis.

But, connecting with a patient also gives the doctor an added sense of respect for the patient that may encourage closer attention to the patient's overall hospital and post-hospital care.

Today it is not unusual for patients to be discharged while still in the early stages of convalescence. Having diagnosed a patient's pneumonia and started proper antibiotic therapy, it is too easy for a resident to rationalize that he/she has done everything necessary for the patient. Because hospitals are penalized for not discharging patients within prescribed time frames, there is a danger that they are conniving at premature discharging of patients and even proud their "through put" prowess. Planting the seeds of "through-put" in the minds of residents can stifle their humanitarian instincts. Thus residents should use the bedside evaluation not only for sharpening their clinical skills and for controlling the urge to resort to extensive imaging and laboratory testing, but also as a constant reminder of the intrinsically human character of medicine and the need to protect it.

Reference

1.Verghese A ,Brady E, Kapur C, Horwitz RI. The bedside evaluation: ritual and reason. Ann Int Med. 2011:155:553.

Conflict of Interest:

None declared

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