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1st May

2017

Diagnostics Dilemma Today: Over Reliance on Technology and Loss of Physical Examination Skills

Over the past several years, we have seen a number of editorials and articles discussing “the lost art of physical examination”, many written by medical school professors, but also by clinicians, including in the field of physical therapy.

Establishing a correct diagnosis is the essential starting point to any successful treatment regimen. However, the process of doing so can be quite complex and time consuming. In health care in the U.S. today, there are a number of factors which can interfere with this crucial process, including pressure put on clinicians to see many patients per day, for shorter periods of time, lack of confidence in one’s examination skills, and presumption that radiological and laboratory tests are more accurate, and provide a better defense in the case of litigation.

However, we know from repeated studies that in the vast majority of cases, it is a good physical examination which leads to a correct diagnosis, whereas imaging and lab tests serve a complimentary role.This is in particular true in musculoskeletal medicine, where past studies on apparently healthy and painfree people in their 40s have shown significant abnormalities on MRI scans, including spinal disc herniations, and tendon tears including large rotator cuff tears in their shoulders, yet these people lived perfectly normal lives. Naturally, such imaging studies play an important role in patients who do present with alarming symptoms and dysfunction, but the imaging results always have to correlate with clinical findings. The problem with technology arises when such tests are ordered without first performing a thorough physical exam.

A paper out of Yale some years back, showed that in 2002, only 24 percent of U.S. medical schools included formal clinical skills courses, while only 4 percent included such courses in the clinical years. This is alarming, and fortunately most medical schools have now made changes to their programs, to increase the emphasis on teaching clinical skills.

In U.S. physical therapy curriculums, time limitations only allow for introductory teaching of manual clinical skills, which take many years to master, and I have yet to encounter a new graduate from physical therapy schools, who has been introduced to, and thoroughly taught the concept of musculoskeletal differential tissue diagnostics. It is much more common that these start out clinicians rely more on the medical diagnosis, or at best on the patient’s history and a few special clinical tests, and use a sort of cookbook approach to treatment, based on an assumed diagnosis, which has not been sufficiently investigated.

John Wooden, the legendary UCLA basketball coach who led his teams to 10 unprecedented national titles, developed his pyramid of success, and understood that it took a tremendous amount of disciplined study, teaching and practice, to achieve such results. One of my most influential mentors, Dr Ola Grimsby, developed the OGI pyramid of differential tissue diagnosis, a complex method to “rule out” and “rule in” possible tissues involved in the disorder or dysfunction, analyzing along the way of the physical examination a large cluster of data, to through a process of elimination reach the most likely diagnosis and movement disorder. This method is being taught and practiced in long-term OGI Residency and Fellowship/PhD programs in orthopedic manual physical therapy. There are today a number of other well respected Residency and Fellowship programs in the U.S. and around the globe.

Unfortunately, the number of graduates from such programs is still quite small in the U.S., and besides becoming an excellent clinician, which in my opinion ought to be enough, there is not much incentive for physical therapists to put in the added time and money required, as they will typically not be compensated higher in group clinics and hospitals, and often their clinical setting will not allow them enough time with each patient to fully apply their skills during the evaluation and treatment.

It is my hope, that in the future we will see a change in this trend, with expanded and more affordable education, including mandatory residency training in different specialties within the field of physical therapy, and an overall health care system which is more efficient and much less bureaucratic (which would require significant health care reform, including of the insurance industry), so that clinicians can do what they are trained to do, spend lots of quality hands-on time with their patients, rather than on the computer.

Technology will continue to march forward, and make our lives easier, and enhance our patient care, but it must never replace the one-on-one human interaction between clinician and patient. Unfortunately, that is not the trend we are seing across the health care field today.

The purpose of this letter is not to spread gloom and doom, but to create awareness, and make people realize that in health care, as in many other service sectors, we are often best served by doing our own research before selecting a provider. After all, it is our health we are dealing with.

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