Family Medicine Vital Signs

By: Sherilyn DeStefano, MD

“Low tech, high touch” is a phrase I first heard used by an integrative medicine provider when I was in medical school. She used it to describe her practice style, one that focused more on physical exam and observation rather than labs and tests. Medical students around the country look forward to when they will learn the time-honored traditions and subtleties of the physical exam, and I was no exception.

Early in our first year, every member of my medical school class received a crisp black fabric bag containing all the physician essentials – stethoscope, otoscope, ophthalmoscope, reflex hammer, and blood pressure cuff. We learned to use those tools through practice on cooperative, mostly healthy standardized patients, but upon leaving the structured world of classroom medicine, found that the exam skills we had so diligently learned sometimes lacked in their ability to reveal the malady afflicting our patient. This can be frustrating to both patient and physician, leading to more questions rather than the sought after answers.

Medical schools have started adding one more piece of equipment to the doctor’s bag, which may someday replace many of the others. Yes, I’m talking about point-of-care ultrasound. Some have called it “the stethoscope of the future,” and while auscultation still reigns supreme in the current era of medicine, more and more studies have found that those aspects of the physical exam which we list under “objective,” may in fact be more subjective than we realize, with surprisingly low interobserver reliability(1,2,3).

Using the example of the pulmonary exam for diagnosing pneumonia, studies have found that the accuracy of commonly deployed physical exam maneuvers to diagnose pneumonia is low (1,4). While a chest x-ray to confirm diagnosis is the most commonly used imaging modality, its use is limited by access and time, not to mention risks such as radiation and challenges in obtaining a good study if patients have limited mobility. Point-of-care ultrasound serves as a potential alternative. It had a pooled sensitivity of 0.85 (0.84-0.87) and specificity of 0.93 (0.92-0.95) for pneumonia when compared to radiographs as the gold standard in a systematic review of the current literature (5). Physical exam, in comparison, had a sensitivity of 0.47 to 0.69 and specificity of 0.58 to 0.756. Granted, ultrasound, like any type of exam maneuver, requires skill on the part of the operator; however, as this technology becomes integrated into medical education, more and more of the practicing population will have the necessary foundation to make this part of their practice. For those who may be concerned they are slightly behind the curve and did not have this exposure in medical school or residency, learning these skills is becoming increasingly possible as ultrasound becomes more ubiquitous with decreasing prices and newer handheld models which can be easily connected to a smartphone or tablet.

I imagine that some may argue that ultrasound takes away from the therapeutic touch that has always been a part of the physical exam. I spent time as a fourth year medical student running around the emergency room, ultra-sounding any patients who were willing to endure some cold ultrasound jelly and multiple passes to get an adequate image for the sake of my education. While I expected people to be unwilling to endure this, to my surprise I found many excited about the possibility of seeing an image of the organs inside them. The setup of ultrasound scanning can actually enhance patient communication and education. Instead of having stethoscope buds in my ears while doing the exam, I can talk while scanning and freezing images to point out various structures to patients. I like to think that the ability to simultaneously diagnose, educate, and have hands-on contact is a type of supercharged therapeutic touch which can only serve to complement the traditional ways of connecting with our patients that we’ve been practicing for years.

I still value what can be learned by a more conventional physical exam, so you won’t see me throwing my stethoscope away any time soon, but I am enthusiastic about this rapidly-expanding technology and how it can help us accomplish a high tech, high touch approach to patient care. While nowhere near proficient yet, I continue to look for ways to improve my ultrasound skills and look forward to continuing to build these into my practice.

References:
1 – Metlay JP, Kapoor WN, Fine MJ. Does This Patient Have Community-Acquired Pneumonia? Diagnosing Pneumonia by History and Physical Examination. JAMA. 1997;278(17):1440–1445. doi:10.1001/jama.1997.03550170070035

2 – Florin TA, Ambroggio L, Brokamp C, et al. Reliability of Examination Findings in Suspected Community-Acquired Pneumonia. Pediatrics. 2017;140(3):e20170310. doi:10.1542/peds.2017-0310

3 – Singal BM, Hedges JR, Radack KL. Decision rules and clinical prediction of pneumonia: evaluation of low-yield criteria .  Ann Emerg Med. 1989;18:13-20.

4 – Graffelman, A. Can history and exam alone reliably predict pneumonia? J Fam Pract. 2007 June;56(6):465-470.

5 – Alzahrani SA, Al-Salamah MA, Al-Madani WH, Elbarbary MA. Systematic review and meta-analysis for the use of ultrasound versus radiology in diagnosing of pneumonia. Crit Ultrasound J. 2017;9(1):6. doi:10.1186/s13089-017-0059-y

6 – Wipf JE, Lipsky BA, Hirschmann JV, et al. Diagnosing Pneumonia by Physical Examination: Relevant or Relic? Arch Intern Med. 1999;159(10):1082–1087. doi:10.1001/archinte.159.10.1082

Sherilyn DeStefano, MD, is a first-year intern in Family Medicine in the Department of Family and Preventive Medicine at the University of Utah in Salt Lake City, UT. Her medical areas of interest include sports medicine and promoting an active lifestyle, women’s health, integrative medicine, medical education, and clinical process improvement.