Volume 186 - Issue 7
Clinical paradigms revisited
Author: Stuart Kostalas
Med J Aust 2007; 186 (7): 381-383. || doi: 10.5694/j.1326-5377.2007.tb00953.x
Published online: 2 April 2007
Published online: 2 April 2007
To the Editor: Schattner1,2 and Wong3 raise issues that examine what has been the core of medical practice since antiquity. Grasping antiquity for its own sake is problematic, at best, and possibly heralds the extinction of long held practices, at worst. As technology improves, we are witnesses to improved imaging modalities that provide higher diagnostic yields, with improved sensitivity and specificity, at increasingly reduced costs. Refusal to even acknowledge the possibility that the history and examination may be terminal is not prudent. Instead, we need to examine carefully our mantra(s) with respect for the temporal nature of medicine.
History and examination evolved in their current form because previous generations could not see inside the body, or examine physiological and pathological processes in real time. Our predecessors amassed a series of verbal cues and physical rules that generally conformed to the presentation of a particular disease. The future of medicine heralds dramatic departure from the world view that preceded computed tomography and magnetic resonance imaging.
Wong raises an important issue with regard to diagnosing emergency abdominal conditions in busy hospital practice. He does not discount a role for the history or physical examination. He does, however, challenge their pre-eminence in “conditions that require emergency surgical treatment”. Is it really in the best interests of patients and the health care system for the emergency department intern/resident, then the registrar/consultant, then the surgical fellow, to all take the history and perform a physical examination? In essence, doesn’t Wong’s “scan first approach” reflect a prudent reliance on, and respect for, the information already gathered?
Schattner4 states that “all imaging studies combined (computed tomography, magnetic resonance imaging, ultrasound, and echocardiography) were decisive in only 10.5% of cases” whereas “the patient’s history and the evolution of the condition proved to be the decisive diagnostic method in 23% of cases”. Doesn’t this show that Wong’s approach provides a heuristic that increases the diagnostic yield, reduces delays and guesswork, and streamlines the processing of patients presenting with acute abdominal pain — or is it acceptable to miss the significant percentage of diagnoses that are decided by imaging alone?!
References
- Schattner A. Clinical paradigms revisited. Med J Aust 2006; 185: 273-275. 0_CBBFJAGG
- Schattner A. Clinical paradigms revisited [letter]. Med J Aust 2006; 185: 672. 0_CBBHDCFI
- Wong K. Clinical paradigms revisited [letter]. Med J Aust 2006; 185: 671-672. 0_CBBFGCAI
- Schattner A. Simple is beautiful: the neglected power of simple tests. Arch Intern Med 2004; 164: 2198-2200. 0_i1091789