Bedside science reduces laboratory art. Appropriate use of physical findings to reduce reliance on sophisticated and expensive methods.

Abstract

During recent decades, we have witnessed the steady downgrading of bedside cardiology as it is constantly being replaced by modern technology. Many, if not most, cardiological diagnoses could be made by use of patient history and the physical examination, supplemented by simple noninvasive procedures, such as the ECG and chest roentgenogram. Newer, increasingly complex techniques become indispensable only when the simpler methods fail or when physicians fail to use them appropriately owing to ignorance, lack of training, or atrophy of previously acquired skills. Access to more sophisticated technologies accelerates these trends in contemporary practice. Newer diagnostic technologies expanded our ability to define anatomic and physiological abnormalities. Our clinical acumen was first sharpened by the correlation between bedside cardiology and cardiac catheterization. Newer, noninvasive confirmatory techniques, such as nuclear medicine, ultrasonography, computed tomography, and magnetic resonance imaging should have further extended and honed our clinical capabilities. Yet these impressive opportunities ultimately weakened transmission and acquisition of physical diagnostic skills. In 300 randomized subjects autopsied in 1960, 1970, and 1980, Harvard investigators reported that 20 years of sonography, scintigraphy, and computed tomography had not reduced the frequency of misdiagnosis.1 A nationwide investigation of trainees in internal medicine and cardiology and third-year medical students demonstrated that the proficiency of bedside cardiac auscultation was seriously degraded.2 Programs with structured teaching in auscultation existed in only 27% of medicine and 37% of cardiology programs.3 Correct answers at the end of an academic year ranged from 0% to 56% for cardiology fellows (median, 21.9%) and from 2% to 36.8% for medical residents (median, 19.3%); these performances equalled those of the third-year medical students. In another survey, 124 internal medicine residents, 11 pulmonary fellows, and 63 medical students in six university-affiliated programs were never exposed to structured teaching of pulmonary auscultation. The auscultatory performance …