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Thursday, April 28, 2011
EPTAS after chapter 6
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Chapter 6 of EPTAS was largely about the use of low-tech physical exam tests in diagnosis. Based on Dr. Sanders' previous attitude on the importance of the physical exam, I was not surprised by the many accounts of cases where an apt physical test, like the Alvarado score for appendicitis, proved faster than a more high-tech expensive test like a CT scan. However, I was surprised at how little doctors know about how effective some tests, like the Adson's test, actually are. It seems like the focus on developing new high-tech tests may have distracted medical researchers from trying to figure out if existing physical exam tests are actually effective. While these new tests are undoubtedly very helpful in some cases, ignoring parts of the physical exam that may or may not be useful is detrimental to patients who could be spared more difficult and invasive tests.
ReplyDeleteDr. Sanders has always supported the use of the physical exam over the use of expensive tests. Chapter 6 focuses intensely on a lot of good examples of the physical (elevating the arm for a sign of thoracic outlet syndrome) while pointing out that there are still a multitude of tests that are useless (Tinel's test). I am not surprised that there are good physical tests (we've had plenty of time to think of those) but I am surprised that many of the useless physical tests are still in use today. Dr. Sanders pointed out that very few people are trying to evaluate and "filter" the effective physical tests from ineffective ones. Clearly, the physical is one of the fastest methods to evaluate certain conditions, but it is not always generally helpful. I believe doctors need to consolidate the differences between the physical and complex tests to more effectively diagnose individuals. I concur with Abby's opinion that doctor's have relied on their devices for their diagnoses and are not focused on perfecting the quicker and cheaper methods of the physical exam.
ReplyDeleteI agree with Dr. Sanders that physical exams are probably the most important of all tests, but I also think that it is extremely awesome that technology allows us to see deeper into the human body. I also think it is very interesting that doctors are not trying to evaluate the different physical test to see whether or not they are more or less useful to the doctor/patient. Truthfully, I am surprised that we don't just have a robot doing physicals nowadays. It's crazy that even though we have a huge amount of technology, humans are still performing surgeries and still doing physical exams. Personally, I think that is a lot better and if when I grow up there are robots doing physicals... I'll be freaked out. Anyways, I agree with both Dryden and Abby that doctors are probably getting lazier as technology expands.
ReplyDeleteBefore reading this chapter I thought that modern-day technology was the key to finding any sort of problem or abnormality within a patient. I think we rely heavily on these new machines to do everything in the diagnosis process and reveal the missing puzzle piece for us that we often overlook the importance of the traditional physical examination. After reading this chapter, I have concluded that it is best to use machines as secondary references when the doctor really can’t detect a problem by the simple act of touching. It seems as though doctors are ordering CT scans and other x-rays often when it is unnecessary (when they could have probably detected the problem through touch). I do see why doctors are uncomfortable with the act of touching their patients because it is a very intimate process when meeting a stranger (or even a close family member). However, I think that it is an intrinsic skill to have as a doctor that with time and patience, will become invaluable. Oftentimes, the awkward barrier between the doctor and patient needs to be broken to really reach a doctor-patient connection. I was fascinated by the story about Dr. Duffy and the buff teacher. From this story, we can see that simple tactile tests can reveal much more than technology may be able to. Dr. Duffy was able to diagnose the patient with his arm in a different position, then confirmed his diagnosis with an MRI. Using CT scans and MRI’s as a source of confirmation seems to be the best way to utilize our growing wealth of technology. As Dryden pointed out, there are multiple tests that do not help at all in the process of diagnosis, but if we continue to practice and discover, I think we will be able to make our physical exam process more accurate and conclusive. I also agree with Abby that doctors are focusing too much of their attention on developing these new machines instead of perfecting the simple but tried-and-true techniques of the physical examination.
ReplyDeleteI agree with Dryden and Alyssa that it's important to study physical exam tests more carefully in order to streamline them and discard the ones that turn out to be useless. This would not only improve the physical exam itself, but also, because doctors would probably respect rigorous scientific tests and studies, improve the standing of the physical exam among physicians.
ReplyDeleteThis chapter really highlighted the importance of physical tests (EFFECTIVE ones). As Alyssa stated, there can be the barrier between the doctor and the patient, but I think that it is crucial that there be a state of complete comfort between the patient and the doctor in such circumstances - a well performed physical test seems to be the best and most valued type of examination, as this chapter stressed. Of course, higher-tech scans and exams are important too, either to confirm hypotheses or to detect problems that cannot be discerned by a physical. But, as Abby and Dryden mentioned, these more modern tests seem to have taken attention away from the physical test, and from filtering effective methods from ineffective ones. These methods have become standard, and instead of focusing energy on finding new, higher-tech methods, doctors should try to better the efficiency of the exams we know to be reliable.
ReplyDeleteMy views on touch haven't changed per se, but like others have said, I feel more convinced that the physical exam needs only to be updated, not eliminated. The anecdote about the young doctors scoffing at that idea was really off-putting for me, especially following the section about Michael Crosby, whose diagnosis was found with a physical technique. Obviously there are pros and cons to using physical examination AND to using technology to make a diagnosis. I don't think it need to be such a "one or the other" situation as some of the doctors in the book believe. Choosing to use both technology and physical examination may be uncomfortable for doctors, because it involves not only the awkwardness Alyssa mentioned but also more mental flexibility. Ultimately, though, it allows them to work more case-by-case than by a formula, ensuring better patient care.
ReplyDeleteI believe that the power of touch is a valuable tool in the doctor's repertoire. Even though the physical tests may not be as accurate as an MRI or electronic exam, I feel like the physical exam makes the patient feel more in control of their diagnoses than getting an MRI, waiting for the results to arrive, then discussing it with their doctors. Psychologically, the patient might feel less helpless when they can, like through Tinel's sign, point to their source of pain rather than getting an X-ray and feeling uncomfortable for a longer time. The physical exam doesn't even take that long to do; the doctor just needs to tap on a nerve and see if the patient responds to the pain. I believe that alleviating the patient's fears and sadness is just as important as alleviating the physical aspects of their diagnoses.
ReplyDeleteIn chapter six, Dr. Sanders delves further into the importance of the physical exam. The physical exam for breast cancer was a strong example of the power of touch. Dr. Sanders stated that around 75 percent of breast cancer cases are discovered by the woman themselves or by a physician through a breast examination: only 25 percent of cases are found through high tech machines. I agree that it is imperative to use helpful and effective examination methods, such as the Alvarado score, before resorting to expensive and lengthy high tech tests. I was surprised by Sanders’ statement that a huge number of patients with abdominal pain are being taken straight to the CT before even a preliminary physical exam. However, I also agree with Leah in that it is odd how little doctors are looking into how effective certain physical exams are. It just doesn’t seem efficient that maneuvers such as Spurling’s sign and Tinel’s sign are utterly unpredictable and yet are still being taught.
ReplyDeleteAfter reading the chapter, I agree with most other people that the physical exam needs to be updated and altered rather than eliminated. My opinions haven't really changed about the power and necessity of touch in the physical exam. I think that the quick diagnostic tests like the Alvarado score are very necessary for the efficiency of medicine; completing more complicated exams is just too costly and time consuming in many cases. I agree with Abby though that it is shocking how little doctors know about the effectiveness of some of these tests. The physical exam needs to be updated, and doctors need to be educated about the inaccuracy of many of these exams. The art of touch is crucial in the physical exam, but doctors need to recognize its limitations as well, and be sure to use more technical methods in conjunction with these tests.
ReplyDeleteIn this chapter, Dr Sanders examined the role of physical examination in making the diagnosis. I am surprised to discover the limitation of physical examination. During her training, Dr Sanders missed the diagnosis of ischemic colitis in an old woman because the patient did not show any abnormality on the examination. She went on to discuss the lack of predictability of certain physical findings such as the Tinel’s sign. Despite that, I still feel that physical examination is a crucial part of diagnosis. To make a diagnosis, we need a thorough history taking and a good physical examination supported by blood tests and imaging. We should not base the diagnosis on one physical finding or one imaging study. I agree with Annaick and Leah how little doctors look into the effectiveness of certain physical examinations. The medical community should not only study the effectiveness of certain physical findings, but also examine the value of expensive technology. It is incredible that most of the patients evaluated in the emergency room got a CAT scan.
ReplyDeleteDan Cohen Period 4
ReplyDeleteI thought that this chapter was extremely interesting and thought-provoking. One thing that I found interesting was the story about diagnosing leg pain. I have tended to agree with the viewpoint put forward in the book in the past and this is no exception. I also thought that the case involving the treatment and diagnosis of appendicitis was interesting as well. It is hard to believe that about 45% of all appendectomies are unnecessary. They said that that is an "acceptable rate" but it seems like if we are going to spend a lot of money paying for expensive CT abdomen scans, we should get a higher realized rate than 45%. I agreed with Annick's comment about how the power of touch in a physical exam is paramount and found it interesting that 75% of breast cancers are found out by the patient finding a lump in their breast. Only 25% of all breast cancers are found by high tech tests yet thousands of these tests are performed (I am not saying to not test people, but I would like to see a more reliable way to diagnose it).
As a stark advocate of technology and technological advances in the medicinal field, I was startled to find the benefits a simple touch can provide. Hands-on examination of a patient truly can make the difference between life and death. Doctors may use tests and machines to help diagnoses, but actually being able to touch and interact with a patient can make all the difference. Making a diagnosis for a patient should involve thorough review of their medical history and a myriad of both old and new procedures. Neither new or old are completely "foolproof" or "better" but the combination of technology and traditional medicine is important.
ReplyDeleteRather than eliminating the medical exam (which I believe would have disastrous consequences) leaders in the medical community need to come to a consensus on the best way to update the procedure.
Dr. Sanders has long shown herself to be a strong advocate of the physical exam, but in Chapter 6 for the first time she analyzes its weaknesses and explains to us ways in which it can be improved. As ever, she emphasizes the importance of efficiently collecting accurate data and then processing that information so as to produce a diagnosis with which the patient can be treated; now she brings up the dilemma of selecting a test that will provide the information essential to reaching a diagnosis, because, as she describes, many old, once tried-and-true tests are in fact unreliable and fairly useless. From her discussion of the lecture about the ineffectiveness of such tests are Tinel’s, it seemed as though there is little being done to come up with new tests that can easily and quickly provide information pertinent to specific conditions, and reinforces the point the book has brought up in earlier chapters that doctors are becoming too reliant on computers and technology and that the physical exam is slowly heading toward becoming obsolete.
ReplyDeleteI agree with Raizel that if the physical exam is going to survive and beat out technology in prevalence for diagnoses, it needs to be updated and doctors need to truly learn well its strengths and limitations. It seems to come down to laziness; if doctors think they can get away with not doing a physical, or learning only the minimum amount of information necessary, they won’t take the time to go in depth and educate themselves about what they’re doing.
This chapter illustrated the importance of seemingly simple physical tests to determine the diagnosis of a sick patient. Despite the proven effectiveness of these physical exam results, high-tech tests are still trusted more and considered more credible. I found the story about patient Michael Crosby and Dr. Tom Duffy very interesting. Duffy’s memory of a test he learned in medical school was the key step in diagnosing the formerly mysterious cause of Michael Crosby’s severe difficulty breathing. After reading the posts of several other people, I agree that the physical exam could be even more effective with some modifications. Also, I think that there is no reason to fully eliminate the physical exam just because more high-tech tests seem to be more trustworthy. Specifically, I agree with Annaick in that one should use simple, low-tech methods of diagnosis before using the high-tech tests. I do believe that high-tech tests serve as a great way of diagnosing a patient, but I think that doing lower-tech tests before using the high-tech tests is a better first step.
ReplyDeleteThis chapter shows that although many are afraid that the physical exam is being replaced entirely by technology, the physical exam as it is is not entirely useful. Many components are outdated and are not accurate, so it's uncertain what parts of the physical exam are completely necessary, so it makes sense that some people would be completely against keeping any aspects of the physical exam. Determining what aspects are useful and necessary and convincing everyone that they are necessary seems to be tricky, as more and more people want to rely only on technology, but relying only on the physical exam poses problems as well, as more doctors are losing the skills necessary. I'm not exactly sure what I think would be a good balance between the physical examination and technology, and I don't really think this chapter cleared that up.
ReplyDeleteI agree with Natalie that Dr. Sanders' analysis of Stephen McGee's lecture seems to indicate that doctors who do still complete the physical exam are not coming up with new tests to replace the archaic ones that have been proven ineffective.
This chapter shows an interesting relationship between touch and technology in the diagnostic process. While Dr. Sanders has talked about the power of touch and the physical exam before, I think the most stunning fact was the statistic regarding breast cancer. Although many women routinely undergo mammograms, 70% of breast cancer cases were discovered by women who could feel a lump in their breast, while 20% were diagnosed by mammograms. Although technology is responsible for a significant part of breast cancer diagnoses, there is also the 5% that is discovered by a physician physical exam. The importance of the physical exam has not yet given way to technology, as shown by systems such as the Alvarado score, which can prove useful for diagnosing appendicitis based on a few simple physical examinations. Nonetheless, as many have said, physical exams need to be carefully looked at, to determine whether or not they are truly effective, and physical exams in general should not be used as the answer to all diagnostic problems. Technological tests should, in my opinion, always serve as a confirmation of whatever diagnosis has been made by a physical exam.
ReplyDeleteI felt that this chapter really emphasized the importance of the physical examinations, a stance which it seems Dr. Sanders has been trying to support throughout the book. As we learned in the previous chapters, many things can be learned about a patient's condition by simply taking the time to look at them and examine their symptoms first hand, rather than relying on the impersonal yet technologically advanced exams that can often unintentionally omit key facts about a case. Dr. Sanders talked a lot about the uncomfortableness of the physical exams on new and aspiring doctors, and I think that a growing reliance on different scanning devices and other medical technologies to replace standard physical exams only aids to the decline in commonality of the physical exams. As Sanders spoke about it this chapter, physical examinations have been crucial in discovering breast cancer in many women where mammograms made up a smaller figure. Though it may seem outdated, I think that it is important that the physical exams remain a standard procedure in trying to diagnose a patient.
ReplyDeleteAfter reaching chapter 6, my views regarding the importance of both the physical examination and high-tech medical tests haven't changed. Sanders, as she does throughout the entire book, makes sure we are aware of this fact. In this chapter, Sanders points out some of the flaws of the physical examination. Tinel's design is one such method of physical examination that has proven to be inefficient, inaccurate, and ultimately outdated. On the other hand, usage of the Alvarado score to assess the abdominal pain of patients has proven to be extremely effective at eliminating many unnecessary appendectomies. I agree with Alyssa's point that we can glean much more from the physical examination if the awkwardness inherent in the patient-doctor relationship is somehow overcome. At the end of the chapter, Sanders asks whether "simply updating our armamentarium of physical exam techniques... [is] enough to reanimate the corpus of the physical exam." Simply put, yes. However, the more important question is how "simple" updating physical exam techniques actually is. I have confidence that we will continue to make advances in medicine (as well as the physical exam).
ReplyDeleteI fell like this section is very similar to the other chapters on the physical exam, or lack there of. Dr. Sanders emphasizes the fact that new tests and new technology distract doctors from more simple methods of diagnosing a patient. One of the main differences between this section and the section on the physical exam is that here, she does address some problems with the physical exam. One of these problems is the Tinel test, it doesn't give a diagnosis and more often gives the wrong signs than the right ones. I think that Dr. sanders wants doctors to step back and identify what works in medical procedure and what doesn't. She hasn't called for medical reform in her book, but it seems that that is the way here book is headed.
ReplyDeleteThis chapter focuses on the replacement of high end technology and tests for the physical exam. although the chapter discusses the often inaccurate results of the physical exam and the outdated procedure i think that through highlighting the physical exams importace we can permanently incorporate it into the diagnostic process. if attention is drawn to the reason for these inaccurate results and the outdated procedures we can hone in on the issues with the physical exam to construct a more efficient and effective physical exam. another way to revive the importance of the physical exam is to acclimatize doctors to deal with the intimacy and often uncomfortable aspects of the physical exam. if we are to construct an exam that not only shows to be effect but is also efficient through well educated doctors i think it would result in a much more effective and efficient diagnostic process that could withstand the pressures of the encroaching technological advancements of medicine.
ReplyDeleteIn the chapter on touch, i was surprised by both the efficacy of some of the physical exams, and by the ineffectiveness of others. I think that based on this we should incorporate more of the effective physical exams into medicine while removing ineffective physical exams as well. I also agree with Johnny that this chapter seems to be rehashing her points on the physical exam from previous chapters.
ReplyDeleteIn this chapter, the replacement of better technological test for the physical exams is discussed. Though there are problems with accuracy regarding the physical exam, many believe that doctors should not completely rely on the new high-tech tests. Because they rely on the high-tech tests, they ignore the good aspects of the physical exams and also ignore why there are/what are the problems with the physical exams. If these doctors pay attention to the problems, they can learn from them and better construct a more accurate and reliable test. Also, if they go back and look at which exams have problems and which don't, they can know which ones to use, and using the good physical exams will save time and money.
ReplyDeleteI agree with alyssa's point about overcoming the awkward patient-doctor relationships to better the results of the physical exams.
This chapter discussed primarily the tendency of doctors to rely too heavily on high tech exams. As usual, Dr. Sanders provided many excellent examples which prove her point that a well performed physical test can be just as reliable (or more so) than the technical counterpart. She did mention, however, that many of the physical tests we still use today are obsolete or don't actually accurately produce diagnoses. This idea of bringing a good physical exam back into the doctor's office is a thematic thread which runs throughout the book, and as I've stated on a past post (perhaps for chapters 3 or 4), I believe there should be a healthy balance between technology and the physical. The power of touch certainly can be very healing as well as very revealing, but there are some things that absolutely must be done with technology.
ReplyDeleteIn this chapter we saw again how doctor's who rely too heavily on tests and technology to do the work for them often do not have as much success in diagnosing quickly. It was interesting though that there are a lot of problems with the regular physical exam as well and those cannot be ignored. It really matters on a case by case basis to decide what will yield the best and fastest results. This is hard to do unfortunately. I think what Johnny said about a possible proposal for medical reform was really interesting and agree that that seems to be where she is headed in her discussion of these problems. It is important to keep the big picture in mind but not to get too caught up in it that we miss the advantages of going case by case.
ReplyDeleteIn this chapter Dr. Sanders further emphasizes the importance and overall effectiveness of physical exams while also discussing the prospect of using expensive technological tests to determine a diagnosis. I was semi surprised at how a physical exam could be capable of yielding results that machine tests and CT scans could miss. I’ve always thought of machine tests to be full proof and able to provide answers that humans could not. Dr. Duffy discovering his patient was suffering from thoracic outlet syndrome by performing a physical exam after the machine tests failed to provide a diagnosis convinced me that the physical exam is significant to modern medicine and should be updated, not eliminated all together. I agree with Alyssa in that doctors continuing to practice and discover can weed out ineffective physical exams and make the process more accurate more of the time.
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