When Done Correctly, the History and Physical Can Save Money

A recent commentary demonstrated that the role of the history and physical examination in achieving correct diagnoses has not been supplanted by the contemporary proliferation of tests and imaging.¹ Well, it did not take long for like-minded studies to drive that truism home with emphasis. Let’s look at a disease with a hefty and increasing prevalence, peripheral neuropathy.

ROLE OF THE HISTORY AND PHYSICAL IN PERIPHERAL NEUROPATHY

Callaghan and coworkers² utilized the 1996 to 2007 Health and Retirement Study Medicare Claims-linked database to identify individuals with peripheral neuropathy (n 5 1031, or 8.1% of a total cohort of 12,673 individuals). The authors observed that the prevalence of this disease is between 2% and 7% of the general population, but it can be as high as 15% among those older than age 40.

Once the diagnosis is made by the history and physical examination, there are guidelines for appropriate and yet limited initial workup.³ What should be ordered? Fasting glucose, a vitamin B12 level, serum protein electrophoresis, and a 2-hour glucose tolerance test (or “GTT” if necessary after a fasting glucose measurement). Seems simple, doesn’t it? Sorry, it is not.

A PLETHORA OF UNNECESSARY TESTS

In the real world, there are a staggering 4001 patterns of testing! Remember our theme: a careful history and physical followed by “appropriate” testing gets the right answer a majority of times. Despite the fact that a GTT is recommended by evidence-based medicine, expensive MRI scans of the brain (remember these are peripheral neuropathies discovered on examination, not brain lesions) or spine are performed more frequently, with 23.2% of the peripheral neuropathy cohort undergoing MRI scans versus only 1.0% receiving GTTs. In fact, brain MRI scans exceeded MRI scans of the spine.

You probably have already guessed the consequence: costs for this plethora of unnecessary tests have increased Medicare expenditures.

A WAKE-UP CALL

The editorialist began his commentary with a quote from The Magic School Bus: “Well, if you don’t look, you don’t see, and what you don’t see can be very hard to find.”⁴ He then makes some profound observations. “A careful history and examination take time, a disappearing commodity in primary care and cognitive-based specialties. . . . It seems the threshold for MRI is often the mere presence of a primary neurologic symptom. . . . Thus the MRI is increasingly viewed as a ‘routine’ test.”⁴ He then says that Callaghan and colleagues’ data² should be a wake-up call.

Readers have responded in favor of a resuscitation of the history and physical examination after the first go-round.⁵ Will there be more joining the clarion call after this paper and commentary?