How valuable is physical examination of the cardiovascular system?

Dear Editors

I am aware this is not directly relevant to cardiovascular examination but Dr Anand has written:

"He says some of his residents don't know how to catheterise or to put up a cannula. It is hard to believe. I thought Australia had erected very good barriers against incompetent doctors. Is it possible that his residents were pretending ignorance and merely wanted him, the headman to give a demonstration."

Believe it or not, it is true. It does not apply to all newly minted interns but there are enough that come through sometimes that it makes me wonder whether the newer clinically based medical school curriculum (basically offloading teaching from university lecturers to clinicians) in some Australian medical schools is helping to prepare students to become doctors any better than the previous medical teaching.

As I have previously written, there is sufficient variation in the abilities of new doctors from different Australian medical schools (such as clinical anatomy: ref 1) such that I believe (just like the GMC UK) that a licensing examination is needed to ensure a national (minimum) standard is set for all doctors to wish to practice in the country (Ref 2,3). Sure, it does not guarantee better doctors but it certainly ensures that local students/overseas trained doctors are aware of the expected basic standard of skill and knowledge and work to achieve it.

On another note, I take issue with his statement "I thought Australia had erected very good barriers against incompetent doctors." In Australia there are national (AMC or Australian Medical Council) examination and assessments of doctors from overseas (but not for local graduates), not unlike PLABs or USLME or MCCEE. This also applies to some other health professionals working in different countries around the world. Some may perceive it as barriers but others consider it very normal and reasonable to dictate a minimum standard expected of health professionals, particularly when there is a need to learn local variations of healthcare standard and guidelines. What is acceptable in a OECD country does not necessarily apply in developing nations and vice versa.

These licensing exams, however, do not guarantee to stop doctors from doing the wrong thing. Throughout parts of the world, including Australia (Ref 4), overseas trained doctors are over-represented in those who are referred to regulating authorities for performance review, although it is uncertain if claims of ethnic discrimination are true in most cases.

Lastly I would like to remind Dr Anand of our shared concerns about the over-reliance of technology to assess and formulate a practical management plan; perhaps he may like to revisit this thread of rapid responses (ref 5) to this article (ref 6). Hopefully it does not reflect the opinion of the current and future generations of doctors.

No doubt technology can assist in clinical care, and some signs and examination techniques should be modified or cast off for their poor efficacies. It is important to improve on (not abandon) clinical examination skills and not to be slaves to machines.

Reference
1. http://www.bmj.com/content/350/bmj.h3467/rr-1
2, http://www.bmj.com/content/350/bmj.h3094/rr-0
3. http://www.bmj.com/content/349/bmj.g5896/rr/774905
4. https://www.mja.com.au/journal/2012/197/8/risks-complaints-and-adverse-d...
5. http://www.bmj.com/content/346/bmj.f3442/rapid-responses
6. http://www.bmj.com/content/346/bmj.f3442

Dear Editors

I would like to address Dr Raza's rapid response.

I wholeheartedly agree with Dr Raza's assertion that physical signs "are still crucial in reaching a clinical diagnosis", and I have written against over-reliance of technology and almost arrogant beliefs that echocardiography can be learnt in many medical schools (ref 1) with their current "progressive" curriculum whereby many aspects of teaching (even at the basic bioscience level) are offloaded to clinicians without adequate access to University resources.

In spite of the emphasis of clinical attachment in modern medical programmes, I still have house officers/interns who cannot insert venous cannulas and urinary catheters or even have not seen a hip or knee replacement before!

However, I do take issue with Dr Raza's surmise that cardiovascular examination of women in certain societies is difficult as result of cultural beliefs and etiquettes to justify "lower threshold for echocardiography requests".

Unless Dr Raza has access to Echo(cardio) sonographers with abilities to use specialised ECHO machines, it is not possible (in the rest of the world) to get adequate ECHO assessment without the use of ultrasound gels and getting the female patients to remove/retract all their clothing to allow direct skin contact of their chest with the cardiac probe. The basic technical premise applies regardless of the gender of the person performing the ECHO.

Perhaps the real difference is that female patients can choose female sonographers, whereas there is less choice in the gender of the attending cardiologist in these societies? Then, rather than using technology to replace/supplement inadequate clinical examination, the real cost effective solution should be to allow more women to have access to medical training on equal terms as men in these countries or overseas so that there are more female doctors/specialists to attend to women in sensitive conditions.

The local government would just have to decide on the balance of allowing more women to participate at all levels of health professional (and deal with conservative/traditionalist elements within their societies) or accept the costly use of technology and third party clinical assessments to deliver a (possibly) different quality of care to half their population.

Somehow I am not certain the former is going to happen for a while.

Reference:
1. http://www.bmj.com/content/346/bmj.f3442/rapid-responses

The author is representing the value of physical examination of cardiovascular system by discussing some of the cardiac signs and their related physical parameters like jugular venous pressure, pulsatile abdominal mass, arterial pulse palpation, lower limb bruits, abdominal bruits, carotid bruits, third heart sound, displaced apex beat and abnormal systolic murmur, etc.

There is always a group of physical findings observed by the clinician, but it is not necessary that all the physical findings of a particular condition are present in all patients suffering from the same physical condition. The author attempted to specify different physical signs with different conditions associated with the cardiovascular system by evaluating their statistical significance with the likelihood ratio (LR).

The LR indicates how much additional value a particular factor helps in assessing the cardiovascular system outcome. Abdominal bruits with systolic-diastolic component have a most significant (LR+ of 39) association for the diagnosis of renovascular disease. Physical examination cannot be a lone criterion to define the problem as stated by the author in case of peripheral arterial disease; the absence of the signs of palpable pulse abnormality and lower limb bruits does not mean the absence of peripheral arterial disease. There are some conditions related to the cardiovascular system which have not been studied like cor pulmonale, pulmonary embolism, etc. So more research is required to include all the conditions. The factors which add some value to the physical examination of the cardiovascular system are accessibility, contribution to clinical care beyond diagnosis, cost effectiveness, diagnosis accuracy, patient safety, patient’s perception and pedagogic value.

A careful physical examination with a complete medical history should be the first step for the physician for diagnosis of the cardiovascular system. These provide the initial database for further diagnostic tests and therapeutic interventions. It is a skill that requires a trained observer who can do it according to the standards. Relying solely on the technological diagnosis without performing the physical examination is not the ideal way of treatment but it is increasingly adopted in rich technological environments. Living in a country with very poor penetration of technological aids due to its higher costs, especially in areas of the lower strata of the population, physical examination forms the first and the foremost method in finding the signs of underlying and impending danger. So physical examination should be a mandatory part in the medical as well as in the paramedical education system.

Vandana Dave1, Dr L.Satyanarayana2

1Msc Medical Anatomy
2Sr.Scientist G NICPR, NOIDA

We thank readers for their comments.

Peter English suggests that physical examination is not just a “set of tests” and we wholeheartedly endorse that view. We expressed the broader value of the physical examination in Figure 3, including its role in the way we teach and learn, but as this was an evidence based review were limited in the space that we could give to our own views on that aspect of the analysis, as evidence of value other than that relating to diagnostic accuracy is relatively light.
 
We support Fernando Geldres' view that the medical education community should ensure that clinical skills are given priority, both in developed and developing countries.

Robert Tanner’s calculations are correct, but required an extreme example of pre-test probablity to make the statistical point. Tests of all sorts are most useful when pre-test probability is intermediate, that is when significant uncertainty exists. A pre-test probability of 1% is not associated with such uncertainty. The figure we provided (Figure 5) indicating the relationship between LR and the change in probability associated with any given LR provides a convenient and relatively memorable means of approximating the change in probability associated with any given LR, but is most accurate in the range of pre-test probability of 10-90% and the figure would have been improved had we stated that fact. As such, the effect of any given LR on post-test probability cannot be said to be entirely independent of the pre-test probability and we apologise if Figure 5 or the podcast discussion, in which exemplar pre-test probability values of 50% and 10% were used, gave that impression.

 
Finally, we too find the “power and magic” that Roger Armour notes in the physical examination – but finding a metric for magic that would satisfy proponents of evidence based medicine was beyond our own power!