Moving Toward Cost-effectiveness in Physical Examination
2014; Elsevier BV; Volume: 128; Issue: 2 Linguagem: Inglês
10.1016/j.amjmed.2014.10.003
ISSN1555-7162
AutoresPaul A. Bergl, Jeanne M. Farnan, Evelyn Chan,
Tópico(s)Healthcare cost, quality, practices
ResumoAt present, 2 trends in teaching clinical medicine seem destined for harmonious marriage or perhaps mutually assured destruction: a renewed interest in physical examination and the push to provide high-value, cost-conscious care.On one hand, the physical examination has been touted as a way to reduce unnecessary diagnostic testing. When applied thoughtfully, physical examination theoretically represents a cost-saving diagnostic maneuver in itself. Indeed, specialty groups such as the American College of Physicians and the American College of Rheumatology have called on clinicians to use physical examination to choose advanced diagnostic tests wisely.1Choosing Wisely Master List. ABIM Foundation; 2013. Available at: http://www.choosingwisely.org/wp-content/uploads/2013/02/Choosing-Wisely-Master-List.pdf. Accessed September 2, 2014.Google Scholar Even specialty societies whose members may gain from indiscriminate testing and imaging have guidelines imploring frontline providers to use clinical skills to avoid unnecessary studies.2American College of Cardiology Foundation Appropriate Use Criteria Task Force American Society of Echocardiography American Heart Association American Society of Nuclear Cardiology Heart Failure Society of America Heart Rhythm Society et al.ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography.J Am Soc Echocardiogr. 2011; 24: 229-267Abstract Full Text Full Text PDF PubMed Scopus (398) Google ScholarHowever, physical examination might represent waste when applied without context. Like any other diagnostic test, physical examination is prone to uncovering incidental findings and false-positives that might beget unnecessary and potentially expensive follow-up testing.3Rothberg M.B. A piece of my mind. The $50,000 physical.JAMA. 2014; 311: 2175-2176Crossref PubMed Scopus (15) Google Scholar Applying aspects of physical examination without a reflection on the prior probability of disease itself may constitute overuse. As such, groups such as the Society of General Internal Medicine have advised against routine health examinations1Choosing Wisely Master List. ABIM Foundation; 2013. Available at: http://www.choosingwisely.org/wp-content/uploads/2013/02/Choosing-Wisely-Master-List.pdf. Accessed September 2, 2014.Google Scholar even though most commercial insurers and Medicare reimburse for them.3Rothberg M.B. A piece of my mind. The $50,000 physical.JAMA. 2014; 311: 2175-2176Crossref PubMed Scopus (15) Google Scholar Perhaps most important, that physical examination can be performed at low cost is merely a mirage; the examination requires the vanishingly scarce commodity of physician time and a substantial upfront investment in training keen clinicians to use these skills reliably and accurately.Although physicians' examination skills are widely believed to be in decline, thought leaders in academia continue to champion the value of physical examination. Here we refer to value in the loosest sense, entailing a spectrum from sentimental to pragmatic. Luminaries in the field of physical examination have called for a cultural change that brings physicians back to the bedside and have implored us to make physical examination both an educational and a research priority.4Verghese A. Culture shock–patient as icon, icon as patient.N Engl J Med. 2008; 359: 2748-2751Crossref PubMed Scopus (227) Google Scholar, 5Elder A. Chi J. Ozdalga E. Kugler J. Verghese A. A piece of my mind: the road back to the bedside.JAMA. 2013; 310: 799-800Crossref PubMed Scopus (31) Google Scholar Moreover, medical schools continue to make substantial investments in teaching examination skills through clinical training centers, paid standardized patients, and protected faculty time for student teaching and feedback.Yet no one seems to be questioning the payoff of such investments, particularly as the use of physical examination as a diagnostic tool, rather than a billing requirement, seems to be fading into obscurity. Encouraging use of physical examination remains a hard sell in clinical medicine, even for students. Competing clinical demands have pushed bedside examination to the wayside. Although the physical examination has been established as an evidence-based diagnostic tool through 2 tomes on the subject,6McGee S. Evidence-Based Physical Diagnosis.3rd ed. Elsevier Saunders, Philadelphia, PA2012Crossref Google Scholar, 7Simel D.L. Rennie D. Keitz S.A. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. McGraw-Hill Companies, New York2008Google Scholar many providers still seemingly rely on advanced imaging or blood tests to "rule in or out" disease. We fear even tireless advocacy for the evidence basis will not turn the tide on the trend to dismiss physical examination. Perhaps then, we need to shift our emphasis to the economic value of the examination and to scrutinize how we teach and deploy the physical examination in delivering cost-effective care. Reframing the discussion around cost provides a common ground on which traditionalists and neophytes might stand together.As we educate the next generation of physicians about the cost-effective physical examination, some educational needs seem obvious. First, routine training of residents and faculty on advanced examination skills is a necessary intervention. In our experience, many physicians have an underdeveloped sense of the physical examination's diagnostic power and limitations. Furthermore, physicians may fail to realize that physical examination could be approached like any diagnostic tool and used only in situations of intermediate probability of disease or diagnostic uncertainty. To stress parsimony and clinical efficiency, a curriculum for the advanced clinician would teach skills that do not require a substantial time investment for mastery and would only incorporate highly discriminating, reproducible findings. It would emphasize selective application of the physical examination in appropriate clinical contexts, recognizing that highly specific findings in a low-risk population are likely false-positives or vice versa. Moreover, an economically focused curriculum would highlight findings that are quickly elucidated in real clinical practice and most likely to obviate advanced diagnostic testing; examples include the Head, Impulse, Nystagmus, Test-of-Skew examination for centrally mediated acute vestibular syndromes8Kattah J.C. Talkad A.V. Wang D.Z. Hsieh Y.H. Newman-Toker D.E. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging.Stroke. 2009; 40: 3504-3510Crossref PubMed Scopus (668) Google Scholar or the Ottawa ankle rules.9Stiell I.G. Greenberg G.H. McKnight R.D. et al.Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation.JAMA. 1993; 269: 1127-1132Crossref PubMed Scopus (294) Google Scholar Such a curriculum would also discourage persistent use of valueless physical diagnosis maneuvers that waste physician time in practice, cause patient discomfort, and occupy precious teaching real estate in medical schools. Finally, evaluation of this curriculum should also include empirical outcomes-based proof that validates the educational investment to improve physicians' examination skills.10Golub R.M. The empiricists strike back: medical education 2012.JAMA. 2012; 308: 2254-2256Google ScholarA movement toward an economically valuable clinical examination must entail more than educating physicians; it also requires a more robust evidence basis and a better understanding of how inattentive examination and inadequate instruction contribute to overuse. Much of the data presented in available texts on evidence-based physical examination rely on older, single-site studies with small sample sizes.6McGee S. Evidence-Based Physical Diagnosis.3rd ed. Elsevier Saunders, Philadelphia, PA2012Crossref Google Scholar, 7Simel D.L. Rennie D. Keitz S.A. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. McGraw-Hill Companies, New York2008Google Scholar Indeed, larger prospective studies could validate certain physical findings and would instill more confidence in our use of physical examination, especially as a means to limit excessive follow-up studies. As others have rightly identified,5Elder A. Chi J. Ozdalga E. Kugler J. Verghese A. A piece of my mind: the road back to the bedside.JAMA. 2013; 310: 799-800Crossref PubMed Scopus (31) Google Scholar the evidence basis of physical examination also needs to be substantiated with outcomes-based data. Patient outcomes can cement bedside examination's role as a cost-savings strategy and a set of skills worthy of our continued educational investment. Research in this field should also explore how better use of physical examination could curb overuse of diagnostic tests. Finally, the scientific community should investigate and prospectively validate more diagnostic algorithms or scoring systems that incorporate known high-yield physical findings with other diagnostic tests. One might imagine a scoring system that uses brain natriuretic peptide levels combined with characteristics of a systolic murmur to predict who would benefit from echocardiography or a peripheral arterial disease score that includes an assessment of pedal pulses combined with pulse oximetry measured at the toe to screen for peripheral arterial disease without ankle-brachial indexes.To inform our understanding of a cost-conscious examination, the academic community could start with qualitative research on clinicians and patients: What advanced diagnostic studies do physicians think they order excessively out of lack of confidence in their examinations? Would patients request fewer diagnostic studies if physicians seemed to possess better examination skills? Do physicians in practice really believe that we can affect our costs of care with a more attentive bedside evaluation or does overuse stem from more deeply rooted problems?Reducing the bedside examination to a strictly economic tool risks ignoring that the examination also may serve a more humanistic purpose: to physically connect with our patients. We fear that the fading appreciation for the physical examination cannot be rescued by sentiment alone though. Selling the next generation of physicians on a more worthwhile clinical assessment in an era of bloating medical costs may represent one of our greatest hopes for saving this critical skill set. At present, 2 trends in teaching clinical medicine seem destined for harmonious marriage or perhaps mutually assured destruction: a renewed interest in physical examination and the push to provide high-value, cost-conscious care. On one hand, the physical examination has been touted as a way to reduce unnecessary diagnostic testing. When applied thoughtfully, physical examination theoretically represents a cost-saving diagnostic maneuver in itself. Indeed, specialty groups such as the American College of Physicians and the American College of Rheumatology have called on clinicians to use physical examination to choose advanced diagnostic tests wisely.1Choosing Wisely Master List. ABIM Foundation; 2013. Available at: http://www.choosingwisely.org/wp-content/uploads/2013/02/Choosing-Wisely-Master-List.pdf. Accessed September 2, 2014.Google Scholar Even specialty societies whose members may gain from indiscriminate testing and imaging have guidelines imploring frontline providers to use clinical skills to avoid unnecessary studies.2American College of Cardiology Foundation Appropriate Use Criteria Task Force American Society of Echocardiography American Heart Association American Society of Nuclear Cardiology Heart Failure Society of America Heart Rhythm Society et al.ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography.J Am Soc Echocardiogr. 2011; 24: 229-267Abstract Full Text Full Text PDF PubMed Scopus (398) Google Scholar However, physical examination might represent waste when applied without context. Like any other diagnostic test, physical examination is prone to uncovering incidental findings and false-positives that might beget unnecessary and potentially expensive follow-up testing.3Rothberg M.B. A piece of my mind. The $50,000 physical.JAMA. 2014; 311: 2175-2176Crossref PubMed Scopus (15) Google Scholar Applying aspects of physical examination without a reflection on the prior probability of disease itself may constitute overuse. As such, groups such as the Society of General Internal Medicine have advised against routine health examinations1Choosing Wisely Master List. ABIM Foundation; 2013. Available at: http://www.choosingwisely.org/wp-content/uploads/2013/02/Choosing-Wisely-Master-List.pdf. Accessed September 2, 2014.Google Scholar even though most commercial insurers and Medicare reimburse for them.3Rothberg M.B. A piece of my mind. The $50,000 physical.JAMA. 2014; 311: 2175-2176Crossref PubMed Scopus (15) Google Scholar Perhaps most important, that physical examination can be performed at low cost is merely a mirage; the examination requires the vanishingly scarce commodity of physician time and a substantial upfront investment in training keen clinicians to use these skills reliably and accurately. Although physicians' examination skills are widely believed to be in decline, thought leaders in academia continue to champion the value of physical examination. Here we refer to value in the loosest sense, entailing a spectrum from sentimental to pragmatic. Luminaries in the field of physical examination have called for a cultural change that brings physicians back to the bedside and have implored us to make physical examination both an educational and a research priority.4Verghese A. Culture shock–patient as icon, icon as patient.N Engl J Med. 2008; 359: 2748-2751Crossref PubMed Scopus (227) Google Scholar, 5Elder A. Chi J. Ozdalga E. Kugler J. Verghese A. A piece of my mind: the road back to the bedside.JAMA. 2013; 310: 799-800Crossref PubMed Scopus (31) Google Scholar Moreover, medical schools continue to make substantial investments in teaching examination skills through clinical training centers, paid standardized patients, and protected faculty time for student teaching and feedback. Yet no one seems to be questioning the payoff of such investments, particularly as the use of physical examination as a diagnostic tool, rather than a billing requirement, seems to be fading into obscurity. Encouraging use of physical examination remains a hard sell in clinical medicine, even for students. Competing clinical demands have pushed bedside examination to the wayside. Although the physical examination has been established as an evidence-based diagnostic tool through 2 tomes on the subject,6McGee S. Evidence-Based Physical Diagnosis.3rd ed. Elsevier Saunders, Philadelphia, PA2012Crossref Google Scholar, 7Simel D.L. Rennie D. Keitz S.A. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. McGraw-Hill Companies, New York2008Google Scholar many providers still seemingly rely on advanced imaging or blood tests to "rule in or out" disease. We fear even tireless advocacy for the evidence basis will not turn the tide on the trend to dismiss physical examination. Perhaps then, we need to shift our emphasis to the economic value of the examination and to scrutinize how we teach and deploy the physical examination in delivering cost-effective care. Reframing the discussion around cost provides a common ground on which traditionalists and neophytes might stand together. As we educate the next generation of physicians about the cost-effective physical examination, some educational needs seem obvious. First, routine training of residents and faculty on advanced examination skills is a necessary intervention. In our experience, many physicians have an underdeveloped sense of the physical examination's diagnostic power and limitations. Furthermore, physicians may fail to realize that physical examination could be approached like any diagnostic tool and used only in situations of intermediate probability of disease or diagnostic uncertainty. To stress parsimony and clinical efficiency, a curriculum for the advanced clinician would teach skills that do not require a substantial time investment for mastery and would only incorporate highly discriminating, reproducible findings. It would emphasize selective application of the physical examination in appropriate clinical contexts, recognizing that highly specific findings in a low-risk population are likely false-positives or vice versa. Moreover, an economically focused curriculum would highlight findings that are quickly elucidated in real clinical practice and most likely to obviate advanced diagnostic testing; examples include the Head, Impulse, Nystagmus, Test-of-Skew examination for centrally mediated acute vestibular syndromes8Kattah J.C. Talkad A.V. Wang D.Z. Hsieh Y.H. Newman-Toker D.E. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging.Stroke. 2009; 40: 3504-3510Crossref PubMed Scopus (668) Google Scholar or the Ottawa ankle rules.9Stiell I.G. Greenberg G.H. McKnight R.D. et al.Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation.JAMA. 1993; 269: 1127-1132Crossref PubMed Scopus (294) Google Scholar Such a curriculum would also discourage persistent use of valueless physical diagnosis maneuvers that waste physician time in practice, cause patient discomfort, and occupy precious teaching real estate in medical schools. Finally, evaluation of this curriculum should also include empirical outcomes-based proof that validates the educational investment to improve physicians' examination skills.10Golub R.M. The empiricists strike back: medical education 2012.JAMA. 2012; 308: 2254-2256Google Scholar A movement toward an economically valuable clinical examination must entail more than educating physicians; it also requires a more robust evidence basis and a better understanding of how inattentive examination and inadequate instruction contribute to overuse. Much of the data presented in available texts on evidence-based physical examination rely on older, single-site studies with small sample sizes.6McGee S. Evidence-Based Physical Diagnosis.3rd ed. Elsevier Saunders, Philadelphia, PA2012Crossref Google Scholar, 7Simel D.L. Rennie D. Keitz S.A. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. McGraw-Hill Companies, New York2008Google Scholar Indeed, larger prospective studies could validate certain physical findings and would instill more confidence in our use of physical examination, especially as a means to limit excessive follow-up studies. As others have rightly identified,5Elder A. Chi J. Ozdalga E. Kugler J. Verghese A. A piece of my mind: the road back to the bedside.JAMA. 2013; 310: 799-800Crossref PubMed Scopus (31) Google Scholar the evidence basis of physical examination also needs to be substantiated with outcomes-based data. Patient outcomes can cement bedside examination's role as a cost-savings strategy and a set of skills worthy of our continued educational investment. Research in this field should also explore how better use of physical examination could curb overuse of diagnostic tests. Finally, the scientific community should investigate and prospectively validate more diagnostic algorithms or scoring systems that incorporate known high-yield physical findings with other diagnostic tests. One might imagine a scoring system that uses brain natriuretic peptide levels combined with characteristics of a systolic murmur to predict who would benefit from echocardiography or a peripheral arterial disease score that includes an assessment of pedal pulses combined with pulse oximetry measured at the toe to screen for peripheral arterial disease without ankle-brachial indexes. To inform our understanding of a cost-conscious examination, the academic community could start with qualitative research on clinicians and patients: What advanced diagnostic studies do physicians think they order excessively out of lack of confidence in their examinations? Would patients request fewer diagnostic studies if physicians seemed to possess better examination skills? Do physicians in practice really believe that we can affect our costs of care with a more attentive bedside evaluation or does overuse stem from more deeply rooted problems? Reducing the bedside examination to a strictly economic tool risks ignoring that the examination also may serve a more humanistic purpose: to physically connect with our patients. We fear that the fading appreciation for the physical examination cannot be rescued by sentiment alone though. Selling the next generation of physicians on a more worthwhile clinical assessment in an era of bloating medical costs may represent one of our greatest hopes for saving this critical skill set. Why the Physical Examination Gets No RespectThe American Journal of MedicineVol. 128Issue 8PreviewSeasoned clinicians recognize the importance of the physical examination, yet many physicians, as Bergl et al1 pointed out--particularly those who are still in training or are new to practice--seem to underestimate its value and place greater faith in imaging studies and blood tests. Full-Text PDF
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