Fear of uncertainty

If a physical exam permits a veterinarian to diagnose a herniated intervertebral disk with only 99% probability, then there is an almost irresistible urge to perform an MRI to close the gap. This is the fear of uncertainty. Further compounding this fear is pressure from the legal profession.

Although a poor reason to order diagnostic tests, the litigious nature of our society often demands it. Since so much more is now known and knowable in veterinary medicine than in the past, our profession is viewed as an absolute science. As a result, more of us are shying away from making educated guesses based on the physical exam findings and are practicing defensive medicine for fear of being sued.

Some believe that it is good science to use our new technology earlier and more prevalently—the technology as a toy argument.² By playing with the toy, we can learn to use it better and, perhaps, discover the unexpected. Moreover, there are greater financial rewards for ordering tests than for picking up on subtle physical exam findings.

Technology can produce good science—the discoveries by Galileo through his telescope, for example.² But technology can mislead, such as when an incidental finding on a radiograph or an artifactually elevated laboratory value on a screening blood test is misinterpreted. And even finely tuned electronic instruments may not offer definitive results.

Nevertheless, we highly value technology. Yet the physical exam has certain advantages over sophisticated tests and tools. For example, it is less expensive, and, unlike many high-tech diagnostic tools, it can be performed anywhere. In addition, the physical exam can be used more easily to make serial observations. And because it involves touch, the exam enhances the veterinarian-patient-client relationship.

In addition, even in today's technologic times, some practitioners still embrace the physical exam as something almost mystical. They see the true value in auscultating the chest or in palpating the abdomen before taking further diagnostic tests. These veterinarians remind themselves that some of the greatest achievements throughout medicine have been based on observation, thorough history taking, and a physical exam. For example, long before the invention of the electrocardiogram, Karel Wenckebach, an early 20th-century physician, discovered the heart block arrhythmia by timing a patient's arterial and venous pulsation.

CONCLUSION

Without a doubt, the veterinary medicine of today is not the veterinary medicine of the last decade. However, despite the many advances in technology, the history and physical exam will remain constants in veterinary medicine. Dermatologists will continue to depend on observation and palpation to recognize skin problems. And neurologists, while greatly helped by computed tomography and MRI, will continue to rely on a patient's history and physical exam results to correlate pathology with functional changes. Practitioners, too, must not lose touch with this central component of patient evaluation.

As Sir William Osler said, "Learn to see, learn to hear, learn to feel, learn to smell and know that by practice alone can you become experts."³ It is the fusion of the physical exam, the patient's history, and technology that will help veterinarians become more accurate, quicker diagnosticians and healers while maintaining the crucial veterinarian-patient-client bond.

David Robbins, DVM
VCA West Bernardo Animal Hospital
11605 Duenda Road, Suite D
San Diego, CA 92127

REFERENCES

1. Phoon CK. Must doctors still examine patients? Perspect Biol Med 2000;43(4):548-561.

2. Flegel KM. Does the physical examination have a future? CMAJ. 1999;161(9):1117-1118.

3. Bean WB. Sir William Osler: aphorisms from his bedside teachings and writings. Springfield, Ill: Charles C. Thomas Publisher, 1961;129.