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Physical Diagnosis 101

Be prepared to stick out your tongue and say, 'Aah,' more often if a recent trend in medical education continues. Schools are emphasizing traditional skills over high-tech, high-cost approaches.


WASHINGTON — A young medical student at George Washington University carefully inserts an otoscope into classmate Quynh Nguyen's ear and pauses in surprise at what he sees--red and inflamed tissue, not the normal pink of a healthy outer ear.

"Um, I think you might have an ear infection," he tells her.

She does, indeed, and that is an unexpected bonus of George Washington's back-to-basics emphasis on the art of "physical diagnosis." First-year medical students regularly practice on one another, mostly to learn what is normal in order to recognize what is not; only rarely do they actually hit the jackpot and find anything wrong.

Until recently, physical diagnosis was becoming something of a lost art as doctors relied increasingly on high-tech, high-cost instruments such as magnetic resonance imaging machines to tell them what was wrong with their patients.

"To some extent, we have gone overboard on tests," says Dr. Robert Keimowitz, dean of George Washington's medical school. "Sometimes having an MRI is essential, but you don't do it on everyone with knee pain. The key is knowing--through better physical examination--when to do it."

Medical educators everywhere are teaching their students to rely more on the less expensive diagnostic tools of yesteryear, and Keimowitz says the cost-cutting climate of managed care is a major motivating force.

"What we are seeing are the health plans saying: 'We don't want you ordering expensive tests when a good physical exam will do,' " Keimowitz says.

Other experts, however, point instead to the conviction of many mainstream physicians that today's young doctors have abandoned or are losing the profession's traditional skills.

"Most of the concern comes from more senior physicians saying that today's whippersnappers don't know how to do it the old-fashioned way," says Dr. David A. Asch, a medical ethicist at the University of Pennsylvania.

"On the other hand, it's probably also true that the more senior physicians aren't much better," he says. "It is merely the case that they practiced during a period when more objective tests were less available, [and so] their view simply wasn't challenged."

At the same time, Asch acknowledges that the cost-saving effects of physical diagnosis make it all the more attractive.


Physical diagnosis came into full flower only in the 19th century, when physicians discarded their traditional diagnostic technique--observation at a distance--in favor of a hands-on approach to try to figure out what was wrong with their patients. Doctors learned by doing over and over again, a process that often taught them more about medicine than any textbook or lecture.

In those days, the most advanced pieces of equipment were instruments that are considered basic today: stethoscopes, ophthalmoscopes, otoscopes. Using them accurately required keen observational skills.

During their first year at George Washington, students begin learning physical diagnosis on one another. They are taught where to place the stethoscope and hear the steady, reassuring rhythm of a healthy heart.

In their second year they start going into the hospital to see patients. Having learned the rudiments during their first two years, every student is expected to know by the third year how to take a complete history and perform a thorough physical.

Keimowitz says that many experienced physicians believe today's med students are slow or reluctant to develop these skills.

"Senior doctors who supervise them come back and often say: 'They don't have it quite right yet.' There just doesn't seem to be enough reinforcement, and we're trying to improve that right now," he says.

He is aiming toward testing medical students at the end of their third year on their ability to take a history and perform a physical exam.

"Students shouldn't complete the program without passing that hurdle," he says.

Just as third-year med students are not as good as first-year residents at performing physical diagnoses, Keimowitz says, "the first-year residents are not as good as the first-year residents of 20 years ago, in part because of this greater reliance on tests."

Keimowitz tells a story about himself to illustrate the fragile and often complicated balance that must be struck between physical diagnosis and the ability to recognize when more objective diagnostic tests are needed.

"Last fall I had a high temperature of 102 degrees for four days, and I diagnosed myself as having the flu," he says. "But I called my own personal physician. He insisted that I have an X-ray--because of the fever.

"It turns out, I had pneumonia. He would have missed it on a physical exam alone, because there are some pneumonias that you can't hear just by listening to the lungs--and this was one of them. But every patient who has a high fever should not have an X-ray."

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