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Boston, MA -Physicians who rely too heavily on high-tech diagnostic tools at the expense of bedside physical examination skills may be missing important prognostic information, Dallas researchers say. In a study appearing in the August 23, 2001 issue of the New England Journal of Medicine, Dr Mark H Drazner (University of Texas Southwestern Medical School, Dallas) et al found that elevated jugular venous pressure and a third heart sound in heart failure patients were each independently associated with adverse outcomes.1
"These findings may increase confidence in the belief that focused bedside assessment is clinically meaningful and may give physicians-in-training further impetus to refine their skills in physical examination," Drazner et al write.
These findings may increase confidence in the belief that focused bedside assessment is clinically meaningful.
At the heart of the issue are concerns that physicians are "becoming less proficient" in the physical examination of their patients, particularly in areas like cardiac auscultation, the authors say. Indeed, Dr Joseph K Perloff (Director, Ahmanson/UCLA Adult Congential Heart Disease Center), who writes an editorial accompanying Drazner et al's study, points out that the stethoscope has replaced the head mirror as "the logo of modern medicine" but that, with fewer and fewer physicians knowing how to use it properly, the stethoscope may fast become "no more than a symbolic gesture to a distinguished past."2
He observes wryly, "the skill with which the instrument is used tends to vary inversely with the prominence of its display."
Putting the logo of modern medicine to use
Drazner et al performed a retrospective analysis of the Studies of Left Ventricular Dysfunction (SOLVD) treatment trial, followed patients with elevated jugular venous pressure or a third heart sound upon trial admission for adverse outcomes over a follow-up period of roughly 3 years. From the 2569 SOLVD patients included in the analysis, 706 had elevated jugular venous pressure (EJVP) and/or a third heart sound.
When these patients were compared to 1773 with no EJVP or third heart sound, the authors found that the group without these physical findings was significantly less likely to die from any cause and/or to be hospitalized for heart failure. Even when NYHA functional class at baseline was considered in the analysis, presence of EJVP or third heart sound appeared to increase hospitalizations from heart failure, as well as the composite endpoint of death or hospitalization for heart failure, and death from pump failure, although not all values were statistically significant.
"These data suggest that the finding of elevated EJVP or a third heart sound on physical examination conveys important prognostic information on patients with symptomatic heart failure," Drazner and colleagues conclude.
Multivariate risk associated with having EJVP or a third heart sound|
Endpoint |
Relative risk |
95% CI |
p value* |
|
Death from all causes | 1.17 | 1.02 - 1.35 | <0.05 |
|
Hospitalization for HF | 1.43 | 1.23 - 1.66 | <0.01 |
|
Death from pump failure | 1.47 | 1.21 - 1.79 | <0.01 |
A step in the right direction
In his editorial, Perloff calls Drazner et al's paper "a step in the right direction," which should "refocus attention on proper technique for the bedside examination of the heart and circulation."
Perloff reviews some of the history of cardiac auscultation, and calls the evidence-based, statistically corroborated study by Drazner et al an "exciting" reflection of the late 19th and early 20th century interest in the diagnostic clues provided by the pulse and pumping heart.
Perloff cautions, "Sophisticated laboratory methods provide contemporary physicians with unprecedented diagnostic information, but reliance on these methods has overshadowed the bedside examination, on which previous generations of physicians depended and were therefore much more adept at performing."
The current paper should therefore spur further analysis of physical signs as prognostic markers, Perloff concludes, and foster a renewed interest in skills essential to the physical examination.
