Is the History & Physical Still Relevant? Readers Respond

I read Dr Gregory Rutecki’s recent commentary “Is the History and Physical Worth Doing Anymore?” with great interest (CONSULTANT, January 2012, page 16).¹

When I was going through my family nurse practitioner (FNP) program, our instructors constantly reminded us of the importance of a comprehensive medical history that would guide our physical examination and help us determine a differential diagnosis.

As an FNP in a walk-in retail clinic, I have only basic exam equipment and a few point of care tests such as urine dips and rapid strep kits. I depend on my skill with the history and physical exam to determine if I can care for a patient or need to refer him or her to a higher level of care. I thank my instructors every work day for their diligence at instilling the importance of a detailed history and physical.

—— Debra Hoffman, RN, MSN, FNP-C

Thank you for your insightful comment. I appreciate your passion about the history and physical’s value. I wish that I could transplant that enthusiasm to my colleagues young and old. 

I may be biased, but you are right in primarily relying on their content to reach a tentative conclusion. I inhabit a world in which CT scans precede a history and physical. That approach is flawed from the get-go.

——
Gregory W. Rutecki, MD
Professor of Medicine
University of South Alabama College of Medicine
Mobile

A well-taken history and physical is the only way to select the appropriate tests, and to find a diagnosis before providing timely and efficient treatment. Waste and complications arise when practitioners request tests without any clue about what is the best diagnostic approach.

I believe that radiology specialists should be consulted when there is any doubt about the best diagnostic procedure. There are scores of contrast materials and scanning machines that were not around a few decades ago.

The main force working against internal medicine, and the worthiness of history and physicals, is the way reimbursement has been designed. Gadgets and instant gratification are both welcomed by patients and physicians, something that will persist until health care funds are spent using evidence-based medicine.

If every internist considered himself or herself a detective, tests would be used in a very organized and justified manner.

—— Higinio Fuentes, MD

I am excited that Ms Hoffman and Dr Fuentes are on the same page with me. I worry, however, that the three of us are a minority in medicine today. Young cardiologists dictate cardiac examinations that read like a stamp: “RRR, no murmurs, no rubs, no gallops.” The echo says otherwise.

I recently had a 20+ year-old patient, previously healthy, who complained of diarrhea and vomiting that for all intents and purposes was consistent with Norovirus infection. She received an abdominal CT scan (it was negative, surprise!) prior to an abdominal exam (also negative and if done initially should have precluded the unnecessary CT scan).

Although the study by Paley and associates,² which I discussed in my commentary, extols the virtues of a carefully performed “H & P,” as do my two colleagues who have written in response, the reality of contemporary practice tells a different tale.

——
Gregory W. Rutecki, MD
Professor of Medicine
University of South Alabama College of Medicine
Mobile

Erratum: The name of one of the coathors of the Photoclinic case "Corkscrew Esophagus" was inadvertently omitted from the August 2011 issue of CONSULTANT.  The authors are Mrugesh Patel, MD, and Mario J. Madruga, MD.  We regret this omission.