Author + information
- Manish Mehta, MD and
- Sanjiv Kaul, MD∗ ()
- ↵∗Knight Cardiovascular Institute, Oregon Health & Science University, UHN 62, 3181 SW Sam Jackson Park Road, Portland, Oregon 97239
We thank Dr. Silverman for his interest in our paper (1). He has raised some interesting points. We agree that at times, a good history allows one to make a diagnosis, and the physical examination is only confirmatory. More often, though, a history and physical examination allow one to create a differential diagnosis, and additional tests are needed to make the definitive diagnosis. One reason why additional tests are needed is because physical examination in itself is not very helpful. Our paper and those of others show that replacing the physical examination by handheld ultrasound (HHU) allows one to make a definitive diagnosis without additional testing in a fair number of patients.
In our study, the physicians performing either physical examination or HHU knew the indication for which the standard echocardiogram has been ordered. Additional testing was based on this knowledge coupled with their examination. Using HHU obviated the need for additional testing in many patients, whereas physical examination left the physicians unsure of their findings, thus requiring more testing.
We did not instruct the cardiologists how to perform physical examination; neither did we instruct them how to use HHU. These were all experienced, board-qualified cardiologists who see patients regularly. Dr. Silverman is correct that most physicians do not perform an optimal physical examination. Any attempt at rectifying it is going to fail, as every medical school faculty member in the past few decades can attest to. It is best to take this on the chin and move on!
Dr. Silverman states that the same people who do a sloppy physical examination will also do a sloppy HHU examination. In our study, HHU and physical examination were performed by cardiologists trained in both, and yet HHU was superior, which tells us that it is perhaps easier to teach HHU than physical examination. We know it is hard for most of us to take, but it is time for the physical examination to go. The sooner we accept it, the better it will be for us, our patients, and health care costs.
Dr. Silverman advises that we should identify conditions where HHU is truly better than physical examination and perform it only in those cases. It is unlikely that we will reserve physical examination for some conditions and HHU for others. Although reluctantly, we will ultimately favor HHU or a similar technology over physical examination, although the transition is likely to be painfully slow!
“I have no doubt whatever, from my own experience of its value, that it will be acknowledged to be one of the greatest discoveries in medicine by all those who are of a temper, and in circumstances, that will enable them to give it a fair trial. That it will ever come into general use, notwithstanding its value, I am extremely doubtful; because its beneficial application requires much time, and gives a good deal of trouble both to the patient and the practitioner; and because its whole hue and character is foreign, and opposed to all our habits and associations” (2). This was a quote in 1821 regarding the stethoscope! Some things never change!
- American College of Cardiology Foundation
- Mehta M.,
- Jacobson T.,
- Peter D.,
- et al.
- Forbes J.