Clinical paradigms revisited

To the Editor: Schattner’s call to resurrect history-taking and examination as the dominant means of clinical diagnosis1 is analogous to advocating a return to cave-dwelling and spear-hunting for food in the era of houses and supermarkets. Even the most ardent supporters of history and examination would acknowledge that they can be grossly inaccurate, in possibly up to 30% of cases.1 Clearly, without using further diagnostic tools, there would be an unacceptably high rate of missed, incorrect or delayed diagnoses with associated morbidity, mortality and financial costs to the patient, hospital and community. Therefore, there is an urgent need to challenge the “politically correct” and entrenched paradigm of history and examination as the initial approach to diagnosis and management.

In my approach to acute abdominal pain, I have long since abandoned using the stethoscope to ruminate over the meaning of mysterious bowel sounds in favour of liberal use of computed tomography (CT) scanning. Gone are the days of inspection, palpation, percussion, auscultation and operation. This often arouses considerable opposition from traditionalist colleagues who are concerned about the cost and radiation dangers of abdominal CT. But their criticism ignores mounting evidence that the modern CT scan is rapid and accurate for nearly all conditions that require emergency surgical treatment.2 In every study comparing the accuracy of CT scans with history and examination, CT wins hands down.2,3 The CT scan takes the guesswork out of diagnosing the cause of abdominal pain and, most importantly, reduces the need for laparotomy procedures that frequently produce negative results. Similar conclusions could be drawn regarding the use of CT scans in head injury or the use of chest x-rays in acute respiratory conditions. Perhaps the new clinical paradigm should be “scan first and talk later”.

So, why do some clinicians continue to routinely promulgate the sacred and arcane ritual of taking a history and doing an examination, which, as diagnostic tools, are clearly second-rate. Cost is not a valid excuse, as there is no reason for patients to accept second-best care. The explanation may lie in blind adherence to ancient dogma that has been unchallenged since Hippocrates. Failure to accept that history and examination have severe limitations; to actively embrace newer, more accurate diagnostic tools; and to revise established clinical paradigms may relegate clinicians to the relevance of dinosaurs outside museums of ancient history. At the risk of medical heresy, I would suggest that the obituary notice for history and examination as the dominant diagnostic tools may be long overdue.