Westby G. Fisher, MD, FACC had me thinking the last couple of days. If he wasn't being sarcastic and he really did have a light bulb experience from this recent finding on electrocardiograms, I had to contemplate why.
Why is there hesitation and lack of certainty to identify some physical complaints using the non-technical, simple approach of asking relevant questions and really listening to a patient's response? Why is there lack of confidence and comfort in taking a good history and performing an examination based on the information obtained from the history? How much should it cost and how much further testing should be required to call a duck a duck? Why is it that confirmation of history and examination generally always occurs via further, expensive diagnostic testing? (Is it really needed?) Then on the flip side from a patient perspective - and, I hear this from patients all the time, "I don't want surgery." So, if a patient doesn't want surgery (whether the person is a candidate or not for surgery), why any further diagnostic testing?
Think of how often we know that in the musculoskeletal world, diagnostic imaging can shed light on some abnormality but the finding really doesn't correlate with the subjective or clinical presentation. If the imaging isn't going to provide some new insight to help guide the treatment, what's the point? What exactly changes when a physician tells a patient, "you have really bad degenerative changes." Wait, let's not go down that path, because that leads to a whole different discussion.
Is there evidence available that can can provide a higher level of value to a good history and examination? Back in 1992, Sackett wrote a nice editorial discussing the barriers (which I believe are still true today) for valuing a good history and examination. At the beginning of that editorial though, he provided 2 statistics to think about: He cited Crombie - 88% of the time a diagnosis was established after a history and short exam; he also cited Sandler - 73% of the time patients were accurately diagnosed after an examination. Sackett did a fabulous job in this article in bringing home the value of evidence-based decisions by comparing the evidence for a few simple questions with advanced diagnostic testing. He tied everything together by using a patient example.
As health care and health care costs are continually analyzed, physical therapists have more value than we may have initially considered. We really haven't been extremely dependent on diagnostic testing to assist in clinical decision-making. Research that focuses on highlighting relevant factors in the history taking and clusters of examination findings (and providing the sensitivities, specificities and likelihood ratios) will strengthen both the value of our diagnosis and our confidence in calling a duck a duck. The other beauty of our role is that society does not expect a physical therapist to order diagnostic testing, which means we can be seen as a viable alternative that breaks the expectation cycle of having every diagnostic test under the sun performed.
Can physical therapists be seen as an integral solution to reducing health care costs? Are we ready to be a part of the solution?
photo by monkeyc.net via Flickr
Selena
