“The physical exam adds information only a small minority of the time – more in the outpatient setting than inpatient. An exam finding does, on occasion, make you feel more comfortable with your diagnosis.”
I liked the article, and comparisons to today’s medicine. I disagree with this point, especially in regard to the outpatient primary care setting. I can think of many examples of patients “telling” us their diagnosis (or at least a solid differential dx) when we put the pieces of history & physical together without any or much extra testing. It is a skill we are in danger of losing when we get too engrossed in following algorithms in & populating our EHRs (as Randall Burchell pointed out in an earlier comment); I would argue we need to continue to use/hone this skill, have more confidence in it (I suspect we all rely on it more in developing our differential than we realize on a conscious level because it is so ingrained in us from our past training & experience) & make an effort to pass its importance on to younger doctors. Thank you for the (RE)VISIT.
My pet peeve is an impression or diagnosis is a symptom or a sign failing to add “DUE TO” this or that. For example SOB is not a diagnosis it needs to be assessed to be due to asthma, increases work of breathing due to… etc.
Much as I like a lot about this post, I would quibble with the term "old-fashioned". This conjures up, at least in my mind, an old, dottering, out-of-date physician who still uses medicines and procedures that have not only gone out of vogue, they were likely pretty useless even in their heyday. I prefer "traditional" or even the more specific "Hippocratic, physician". These physicians meet nearly all the criteria of the so-called "old-fashioned" physician. They see patients themselves and take the time necessary to obtain a proper history and perform an appropriately focused or broad physical examination. They assemble a differential diagnosis then set about obtaining the necessary tests to confirm or refute each. They try hard to avoid over- or under-treating patients. They are slow to adopt new things and only when they are convinced these are better than what came before. They ask for help or consult appropriately but maintain oversight over the patient. They operate only when necessary but do not hesitate to do this when appropriate. They follow the patients themselves. I could go on. While advances in pharmaceuticals, procedures, devices, and operations will render much that we used to do obsolete, nothing will change the underlying sine qua non of good medicine: the relationship between physician and patient. Patients cannot be reduced to RVU's, their medical care dictated by flow charts and "best practices", their physicians pressured to do ever more in ever less time, and primary care relegated to "mid-levels" (who came up with this term?) whose education and training is a small fraction of that obtained by MD/DO's without the quality of medical care suffering, as it is clearly doing in my view. As I near then of a 46 year medical career, as a general surgeon first and later a plastic surgeon, I would like to be able to say I am leaving medicine better than I found it. Alas, I cannot. R. Bosshardt, MD, FACS
I (& my younger brother commenting above) had the great fortune to spend my sleepless house staff years (prior to any Bell Commission work hour limitations) under the tutulege of both master clinicians Drs. Jim Willerson & Herb Fred. I (now fondly) recall being tossed out of morning report by each for presenting a case missing a key piece of history or bedside maneuver, but those lessons have served me well over now 30+ years of both academic & private practice Internal Medicine. They both exemplified my favorite axiom: "the greatest secret of caring for a patient is.... Caring for the patient". May they both rest in the eternal peace they've earned by their service to their patients & fellow clinicians.
I certainly prefer terms like experienced to "old fashioned" which has some negative connotations. Many think that the wisdom that comes with age and experience means more knowledge but the older I get the more I realize that true wisdom is learning how much you don't know and framing your decisions accordingly. Thank you for this wise reflection.
Disagree that testing can be hypothesis generating. The rational use of testing involves a tentative diagnosis, pre test odds, accuracy/false positive/false negative rate of the test and the post test likelihood of a correct diagnosis. If there is no understanding of the pre test likelihood, then you are likely to discover a large number of incidental findings that may or may not have anything to do with the person’s symptoms. Personal experience of 40+ years in surgery, I had many calls for findings that were not problems.
The tribute to Dr. Fred in the Texas Heart Institute Journal is lovely, as is the mention of the importance of his mentor Dr. Wintrobe. We who find teachers who embody our professional ego-ideal are so very fortunate. I wrote about mine here as a tribute to the gift of their positive influence:
The intensified demands on physicians and many other professionals, coupled with a loss of control and status, make it very difficult to be the good "old-fashioned" variety we all wish for when we seek help and advice. We all lose in the bargain.
As a retired surgical nurse I have to speak in defense of radiology and blood testing. I saw unnecessary surgeries based on assumptive exams without evidence of disease.
Adam, I think this is your best article I have read. Putting Dr. Fred’s observations and tenets in a present day context illustrates and explains so much of the stress and burn-out among physicians who approach their patients with compassion and critical thinking skills. Too often, we see patients who have had 3 CT scans, serial high-sensitivity troponins and ECGs, and consultation requests to 4 different subspecialists, all in the first couple of hours after arriving at the hospital. As an “old-fashioned doctor” consultant, disappointment occurs upon discovering there is no differential diagnosis or demonstration of thought clarity within the 9 page “history and physical” created by the guideline-directed hospitalist key stroking the template-infested EMR. Unfortunately, the discharge summary is but a 20 page regurgitation of the 8 hour and $30,000 ER visit when it could have been better communicated with a 2 paragraph composition summary of what happened. I encourage your readers to link to the excellent article written by Dr. J.T. Wilkerson commemorating the life of Dr. Fred. We should all realize what American medicine has lost with the absence of educators like Dr. Herbert L. Fred. The comments to this article by your readers have been encouraging.
Back when you or your insurance company paid for a block of time with your doctor, not the number of tests, procedures, and meds ordered, done, and prescribed during your visit. Back when the doctor used their clinical experience and judgment rather than doctoring by protocol to avoid negative consequences (and not to their patients). I saw the change happen before my eyes, where a cash visit to the pediatrician was $40 or $10 with insurance. This was the early 90s.
“The physical exam adds information only a small minority of the time – more in the outpatient setting than inpatient. An exam finding does, on occasion, make you feel more comfortable with your diagnosis.”
I liked the article, and comparisons to today’s medicine. I disagree with this point, especially in regard to the outpatient primary care setting. I can think of many examples of patients “telling” us their diagnosis (or at least a solid differential dx) when we put the pieces of history & physical together without any or much extra testing. It is a skill we are in danger of losing when we get too engrossed in following algorithms in & populating our EHRs (as Randall Burchell pointed out in an earlier comment); I would argue we need to continue to use/hone this skill, have more confidence in it (I suspect we all rely on it more in developing our differential than we realize on a conscious level because it is so ingrained in us from our past training & experience) & make an effort to pass its importance on to younger doctors. Thank you for the (RE)VISIT.
My pet peeve is an impression or diagnosis is a symptom or a sign failing to add “DUE TO” this or that. For example SOB is not a diagnosis it needs to be assessed to be due to asthma, increases work of breathing due to… etc.
Much as I like a lot about this post, I would quibble with the term "old-fashioned". This conjures up, at least in my mind, an old, dottering, out-of-date physician who still uses medicines and procedures that have not only gone out of vogue, they were likely pretty useless even in their heyday. I prefer "traditional" or even the more specific "Hippocratic, physician". These physicians meet nearly all the criteria of the so-called "old-fashioned" physician. They see patients themselves and take the time necessary to obtain a proper history and perform an appropriately focused or broad physical examination. They assemble a differential diagnosis then set about obtaining the necessary tests to confirm or refute each. They try hard to avoid over- or under-treating patients. They are slow to adopt new things and only when they are convinced these are better than what came before. They ask for help or consult appropriately but maintain oversight over the patient. They operate only when necessary but do not hesitate to do this when appropriate. They follow the patients themselves. I could go on. While advances in pharmaceuticals, procedures, devices, and operations will render much that we used to do obsolete, nothing will change the underlying sine qua non of good medicine: the relationship between physician and patient. Patients cannot be reduced to RVU's, their medical care dictated by flow charts and "best practices", their physicians pressured to do ever more in ever less time, and primary care relegated to "mid-levels" (who came up with this term?) whose education and training is a small fraction of that obtained by MD/DO's without the quality of medical care suffering, as it is clearly doing in my view. As I near then of a 46 year medical career, as a general surgeon first and later a plastic surgeon, I would like to be able to say I am leaving medicine better than I found it. Alas, I cannot. R. Bosshardt, MD, FACS
My last piece 'In the beginning Part 3' underscores your thoughts on this issue - thank you!
Veronica Sweet is a practicing old fashioned doctor. God’s Hotel on Amazon
I (& my younger brother commenting above) had the great fortune to spend my sleepless house staff years (prior to any Bell Commission work hour limitations) under the tutulege of both master clinicians Drs. Jim Willerson & Herb Fred. I (now fondly) recall being tossed out of morning report by each for presenting a case missing a key piece of history or bedside maneuver, but those lessons have served me well over now 30+ years of both academic & private practice Internal Medicine. They both exemplified my favorite axiom: "the greatest secret of caring for a patient is.... Caring for the patient". May they both rest in the eternal peace they've earned by their service to their patients & fellow clinicians.
I certainly prefer terms like experienced to "old fashioned" which has some negative connotations. Many think that the wisdom that comes with age and experience means more knowledge but the older I get the more I realize that true wisdom is learning how much you don't know and framing your decisions accordingly. Thank you for this wise reflection.
I’m much to young to be an old-fashioned doc yet here I am deprescribing and listening
Disagree that testing can be hypothesis generating. The rational use of testing involves a tentative diagnosis, pre test odds, accuracy/false positive/false negative rate of the test and the post test likelihood of a correct diagnosis. If there is no understanding of the pre test likelihood, then you are likely to discover a large number of incidental findings that may or may not have anything to do with the person’s symptoms. Personal experience of 40+ years in surgery, I had many calls for findings that were not problems.
The tribute to Dr. Fred in the Texas Heart Institute Journal is lovely, as is the mention of the importance of his mentor Dr. Wintrobe. We who find teachers who embody our professional ego-ideal are so very fortunate. I wrote about mine here as a tribute to the gift of their positive influence:
https://bairdbrightman.substack.com/p/the-magic-of-mentors
The intensified demands on physicians and many other professionals, coupled with a loss of control and status, make it very difficult to be the good "old-fashioned" variety we all wish for when we seek help and advice. We all lose in the bargain.
As a retired surgical nurse I have to speak in defense of radiology and blood testing. I saw unnecessary surgeries based on assumptive exams without evidence of disease.
My last piece 'In the beginning Part 3' underscores your thoughts on this issue - thank you!
Love the Vonnegut quote!
A somewhat similar glimpse of medicine in the 1990's is: http://userwebs.inreach.com/famdoc/artfulscience.html
Adam, I think this is your best article I have read. Putting Dr. Fred’s observations and tenets in a present day context illustrates and explains so much of the stress and burn-out among physicians who approach their patients with compassion and critical thinking skills. Too often, we see patients who have had 3 CT scans, serial high-sensitivity troponins and ECGs, and consultation requests to 4 different subspecialists, all in the first couple of hours after arriving at the hospital. As an “old-fashioned doctor” consultant, disappointment occurs upon discovering there is no differential diagnosis or demonstration of thought clarity within the 9 page “history and physical” created by the guideline-directed hospitalist key stroking the template-infested EMR. Unfortunately, the discharge summary is but a 20 page regurgitation of the 8 hour and $30,000 ER visit when it could have been better communicated with a 2 paragraph composition summary of what happened. I encourage your readers to link to the excellent article written by Dr. J.T. Wilkerson commemorating the life of Dr. Fred. We should all realize what American medicine has lost with the absence of educators like Dr. Herbert L. Fred. The comments to this article by your readers have been encouraging.
Thanks so much J.
Adam
Back when you or your insurance company paid for a block of time with your doctor, not the number of tests, procedures, and meds ordered, done, and prescribed during your visit. Back when the doctor used their clinical experience and judgment rather than doctoring by protocol to avoid negative consequences (and not to their patients). I saw the change happen before my eyes, where a cash visit to the pediatrician was $40 or $10 with insurance. This was the early 90s.