Reply
Y. Chandrashekhar, MD, DM, FACC,
Jagat Narula, MD, PhD, FACC*
We thank Dr. Michelena for raising an important issue in response to the Editor's Page (1). Being from a sandwich generation, having master clinicians as our teachers and technology-focused fellows and residents as our students, we ourselves cannot but be nostalgic about the lost art of the clinic examination. All of us have had success stories in which we made bedside diagnoses that would have made our master teachers proud. However, in far many more cases, we also remain acutely aware of our limitations at the bedside. The world of medicine is moving on very briskly and relying exclusively on a very restricted view of what a good clinician can use at the bedside (the touch, the smell, sound, and feel as beautifully described by Dr. Michelena) or cannot use in a complimentary fashion (imaging) is, in our view, unhelpful.
Dr. Michelena's premise is possibly based on subscribing to rather inelastic boundaries for a traditionally defined clinician. In some ways this suggests and "us versus them" scenario; ownership of history and physical exam (and using the stethoscope as its final elegant instrument of proof) to the exclusion of other easily available tools (used by imagers in their dark laboratories and not by clinicians at the bedside). This we feel is an artificial distinction and would argue that easily available imaging is a natural and complimentary extension of day-to-day clinical practice. Thus, the concept of a clinician-imager was emphasized in our proposal. All of us will agree that getting to the correct diagnosis, in the safest and most expeditious manner, is an important goal in clinical medicine. The clinician's right to using only a stethoscope to the exclusion of say, complimentary use of the hand-held ultrasound (when the latter provides far superior information), is rather artificial and possibly sets us up for less-than-optimal patient care.
One of our master clinician-teachers used to often say, "In God we trust but everybody else must show proof." There is much evidence that imaging provides incremental value in the diagnosis and, in fact, a lot of clinical information not supported by imaging data is often reassessed in clinical practice. Therefore, it is likely to anchor the physical exam in the future; the remaining debate in imaging is about more complex issues like societal costs and whether testing changes outcome. However, test performance characteristics of traditional auscultation methods remain mostly untested or dismal when tested, especially in the current training environment (2,3). It is less likely to get better even with seniority (2). We should also appreciate that diseases, once defined only by obvious physical findings or classic symptoms, are now being detected and sometimes treated (e.g., patent foramen ovale in recurrent cryptogenic stroke) very early before such findings appear. Imaging is showing disease where little was suspected clinically (4). Finally, questions (like filling pressures, left ventricular function, viability, risk of sudden death, and so on) are being asked that are outside the ambit of traditional touch, smell, sound, or feel. One would suspect that even Leatham, Wood, and Harvey would approvingly allow easily available imaging techniques into their clinical armamentarium if they practiced today.
Of course, this assumes an optimally obtained imaging study. The issues of training requirements and test performance at the bedside would need to be standardized to reap the maximum benefits from powerful imaging modalities. Nevertheless, in our view, these issues are manageable and possibly inevitable given the push to quality in clinical medicine. Unless unexpected changes in economics play an adverse role in the development of miniaturized technology, imaging that makes "believing" more possible is destined to play an increasingly useful role at the bedside.
* Editor-in-Chief, JACC: Cardiovascular Imaging, 3655 Nobel Drive, Suite 630, San Diego, California 92112 (Email: narula{at}uci.edu).
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REFERENCES
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- Chandrashekhar Y, Narula J. iJACC in the evolving world of integrated imaging: a spectator, a follower, or a trail blazer J Am Coll Cardiol Img 2008;1:691-693.[Free Full Text]
- Mangione S, Nieman L, Gracely E, Kaye D. The teaching and practice of cardiac auscultation during internal medicine and cardiology training Ann Intern Med 1993;119:47-54.[Abstract/Free Full Text]
- Shaver JA. Cardiac auscultation: a cost-effective diagnostic skill Curr Probl Cardiol 1995;20:441-532.[Medline]
- Marijon E, Ou P, Celermajer DS, et al. Prevalence of rheumatic heart disease detected by echocardiographic screening N Engl J Med 2007;357:470-476.[Abstract/Free Full Text]
Related Article
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Seeing or Hearing to Believe, or Both?
- Hector I. Michelena
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