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Sports Physicals, Sudden Death, and Chiropractors

A correspondent sent me a link to an article about the decision of the Wichita Falls (Texas) Independent School District to recommend that chiropractors be allowed to give sports physicals to junior high and high school students. Current policy limits examiners to physicians, physician assistants, and nurse practitioners. Adding chiropractors to this list would bring the district in line with policies in the rest of Texas, as well as in some other states. And it would “give parents more options.”

I’ve written about the attempts of some chiropractors to assume the role of family doctors and why I think it is a terrible idea. The idea of allowing them to do sports physicals impresses me as somewhat less terrible, but not by very much.

The Reasons for Requiring Sports Physicals

The goals of the Pre-participation Athletic Exam (PAE) include:

  • To identify athletes who should not participate because of high risk of injury or death
  • To identify those who require further evaluation or treatment so they can participate safely
  • To identify conditions that do not affect athletic participation but that should be treated
  • To possibly identify those at risk for substance abuse, depression, violence, etc.
  • To provide preventive health advice
  • To satisfy legal requirements.

According to a review article in American Family Physician

 Specific conditions that would exclude or limit athletic participation include hypertrophic cardiomyopathy, long QT interval syndrome, concussion, significant knee injury, sickle cell disease and uncontrolled seizures. Overall, about 1 percent of athletes who are screened are completely disqualified from sports participation.

The greatest concern is the risk of sudden death.

Sudden Cardiac Death

In the 5th century BC, Phidippides ran 25 miles to bring the news of victory in the battle of Marathon to Athens. After delivering his message to the archons, he collapsed and died. Sudden death during or immediately after athletic exertion continues to be a problem. Estimates of incidence range from one young athlete in 200,000 every year to 1 in 43,770 NCAA athletes and 1 in 3100 NCAA Division I male basketball players per year. A Minneapolis Heart Institute Foundation study of sudden deaths in trained athletes identified 158 deaths, 85% due to cardiovascular causes. Hypertrophic cardiomyopathy was the most common cause. Physical exams are not very good at preventing these deaths.  115 of these athletes who died suddenly had had a standard preparticipation medical evaluation, and only 4 of them had been suspected of having cardiovascular disease. Of those 4, the abnormality responsible for sudden death was correctly identified in only one.

An article in the Journal of Athletic Training characterized current screening methods as “ineffective and inefficient.” The standard history and physical exam result in an extremely small number of significant cardiac findings. Screening ECGs have been proposed but are generally considered to be ineffective because of the high false positive rate. In a study of 501 college athletes, 75 had abnormal ECGs requiring further examination, but none of them led to restrictions from participation.

Italy has an aggressive screening program that disqualifies 1.8% of athletes for

  • physical features of Marfan syndrome;
  • delayed femoral arterial pulses;
  • single, wide or fixed splits in the second heart sound;
  • systolic or diastolic murmurs of grade 2/6 or greater;
  • irregular rhythms; or
  • blood pressures greater than 145/90 mm Hg

This screening reduced the mortality of young competitive athletes by approximately 90%.  But other sources show that the overall SCD incidence in Italy remains similar to that in the US.

Screening all athletes with echocardiography would identify many athletes at risk for sudden death, but it would cost an average of $857 per patient.  False positive findings may lead to expensive further evaluations, and there are emotional costs (worry, stress, persistent fear of death even after reassurance of normality). There are also false negatives.

The American Heart Association has a list of recommended screening items including family history of sudden death and cardiovascular disease, personal history of 6 specific symptoms, 4 physical exam items, and parental verification. In one review, only 17 of 43 state forms met AHA recommendations.

Non-Cardiac Problems

Blood pressure, weight and vision are tested. The PAE can identify patients with post-concussive sequelae to help prevent second-impact syndrome. Patients with a single eye,  sports injuries. Patients with seizure disorders can be dissuaded from high risk sports like high diving. Exercise induced asthma can be treated. Patients with sickle cell trait can be counseled about hydration and acclimatization. Old injuries can be assessed for complete healing. Tests like duck-walking (walking in a deep squat) can detect a torn meniscus. Eating disorders may be identified. Contagious skin infections may be spotted.

There are other benefits.  The exam offers an opportunity to address prevention issues (smoking, seatbelt use, etc.). It can identify health concerns that don’t directly affect participation but that need further evaluation and treatment.

How Are Sports Physicals Done?

There is a standard form for these exams that is recommended by several medical organizations. Not all schools use this form, but all have some kind of history form to be completed by student and parents, and a checklist for things to be looked at in the physical exam.

The history is the most important part of the process, identifying up to 78% of pertinent conditions.  Unfortunately, as Dr. House says on the TV series, “patients lie.” Children and parents are motivated to get clearance to play a sport and may intentionally omit or minimize symptoms or past illnesses/injuries that they think might disqualify them. The ideal examiner is the child’s personal physician who already knows the health history and family history in depth. A family physician or pediatrician has the broad training to pick up potential problems in all areas.

Other than the cardiovascular exam recommendations from the AHA, there is little guidance about which physical exam components are worthwhile. Should we have every patient duck-walk to test for meniscal tears in the knee? Is measuring every child’s height really important? How often does a cursory exam for enlarged lymph nodes lead to a significant diagnosis? When the form calls for musculoskeletal exam of the wrist/hand/fingers, should we just look to see if all the fingers are there, or should we test strength, flexibility, and range of motion? What criteria define a significant finding in this context, and what actions are indicated for positive findings? We simply have no evidence to guide us.

There are two ways to get these exams. Students can be seen by their personal physician; but this involves cost and inconvenience, and timely appointments may not be available. Some schools offer mass screening exams with an assembly line of stations where individual tasks are accomplished, like vision testing and BP measurement, ending with a station where a physician reviews the results and examines the patient. This method is cost-effective and time-effective, but it may decrease quality.

I have participated in those mass screenings, and I hated them. They were a chore to be endured, with limited time for interactions with the patient and with little sense of purpose.  Back when I was doing them we had no guidance and little understanding of what we should be looking for; and it easily degenerated into a perfunctory task of checking items off on a list with the feeling that it wasn’t going to make any difference to anybody anyway. Only around one percent of patients have a disqualifying condition, and it can be very tedious to wade through the other 99.  I’ve always disliked doing routine physicals of any kind, because they are largely unproductive, as I explained in another post.  Doing a physical in pursuit of a diagnostic problem is fun, stimulating, and rewarding. Listening to the normal hearts of 99 often shy and embarrassed teen and pre-teen strangers is not. I’d much rather see a regular patient in my office and fill out the form based on a long-term relationship and a limited, directed physical exam.

Who can do these exams?                     

  • 5 states have no specific recommendations
  • 21 states allow PAs and NPs to perform these exams
  • 10 states allow chiropractors
  • 1 state allows naturopaths
  • Colorado allows chiropractors to do school physicals but requires special training and certification.

Some PAs and NPs have enough training and experience to detect cardiovascular disease, but few chiropractors do. Specific training might bring selected chiropractors up to an acceptable level, but there are other considerations. They might miss things because they still would not have the broad experience of all kinds and severities of illness that physicians get with in-hospital training, and they might be influenced by belief systems that are outside the scientific paradigm.  Less than half of chiropractors support immunization, many of them use bogus muscle testing (applied kinesiology), and many of them still imagine they are correcting mythical subluxations: those at least would have to be excluded. And they would have to be prevented from soliciting customers for chiropractic adjustments and from spreading misinformation. The whole thing is just too problematic.

Questions and Answers 

Q: How effective is the sports physical for identifying health problems?

A: Not nearly as effective as it could be.

Q: Which health problems should preclude athletic participation or defer it pending further testing?

A: Controversies exist; there are few absolutes, and the degree of risk varies with the magnitude of the problem.

Q: Does the requirement for sports physicals reduce the rates of injury or death?

A: There’s some evidence that it does, but it’s not entirely conclusive, and the reduction is likely small in magnitude.  And even if barred from athletic programs a young person may choose to ignore advice and risk injury or sudden death by strenuous recreational exertions.

Conclusion (AKA My Humble Opinion)

Sports physicals have the potential to significantly reduce the risk of injury and death, but in actual practice they are often inadequate. They could be improved by standardization and more rigor, including uniform application of AHA recommendations. Ideally, they would be done by the child’s family physician. Ideally, examiners would have specific training in what to look for and which exam procedures to use, training that will be problematic until we can support specific recommendations with better evidence.  Physicians and properly trained, experienced PAs and NPs are qualified to do these exams. Chiropractors and other alternative providers are not, even with special certification and training.

Posted in: Chiropractic, Public Health

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72 thoughts on “Sports Physicals, Sudden Death, and Chiropractors

  1. BillyJoe says:

    The Melbourne Marathon was run last Sunday. Participants were not required to have pre-participation medical examinations. There were 30,000 runners. Nobody died.
    I missed out because of tendonitis.

    Next Sunday, the 210 kilometer Round The Bay bicycle race will be conducted. I will be participating for the first time (fortunately, the tendonitis does not affect my cycling). I have not had a pre-participation medical examination. I do not expect to die.

    Stay tuned…

  2. Janet says:

    How can chiropractors even pretend to be qualified to detect cardiovascular disease? Is their coursework standardized anywhere? Is their training in any way comparable to medical school? Why do people take children to chiros anyway? These are not rhetorical questions.

    This trend to equating anyone who has attended some “college” with a medical doctor who has completed training, internship, and residency at an accredited hospital is worrisome–at best. I’m not even sure NP’s are the answer. Every time I’ve seen a NP, or even a PA (and this is becoming increasingly common), the doc comes in after and goes in another direction entirely. I’ve come to think the NP’s and PA’s are mostly there to spend some time with the patient listening to her complaints, and then summarizing for the busy doctor. Few of them have given me the confidence I would want to have in terms of looking for life-threatening problems in my child, but at least they have real medical training and are supervised by MD’s.

    (The exception with NP’s was in my childbearing years. They were very good in those days, although, mostly because they listened and made me feel more comfortable–they were the first ones to warm up the speculums (specula?) and bother explaining to you what was going on. But that was a long time ago. The young (male) gyn I have now is a world apart from the patriarchal types of my youth.)

  3. Scott says:

    @ Janet:

    You will find the overriding answer to your questions, I think, in the subtitle for Spaceballs 2.

  4. mousethatroared says:

    This may not be exactly relavant, but I wonder if some sort of local tracking of team injuries would be helpful for prevention. A few years ago a teen-ager I know got a stress fracture during a high-school competitive sport. the parents found out later, through word of mouth, that two kids in the same team had previously gotten the same injuries. These were not minor, ankle sprain, type injures, in retrospect they appeared to be the result of coaching error, hopefully preventable.

    Then there’s the new awareness of the risks of head injuries in football and the reports of overuse sport injuries in younger kids…

    Pediatric sport medicine, the wave of the future.

  5. windriven says:

    I am pleased to offer sports physicals in the 5 states with no particular credentialing required. I am able to offer this service for a most attractive price by using the ancient Tibetan system of Distant Physical Reading. The athlete-to-be simply holds a US $100 bill to his/her left patella (the seat of athletic prowess in my honored belief system) for exactly 5 seconds, then mail it to me. The athlete is then free to participate in any and all sporting activity. I do not send a report as such because Distant Physical Reading is prophylactic as well as diagnostic.

    But wait, there’s more! My results are guaranteed to equal or surpass those of even the best chiropractors. So don’t wait, this is a limited time offer!

  6. Alia says:

    @BillyJoe
    Last Sunday there was also a marathon in Poznań, Poland. Participants were not required to have pre-participation medical examinations, they just signed forms that they are fit enough. There were 6,000 runners. And a 35-year-old man died of a cardiac problem on his 14 km.

  7. Quill says:

    As a former subject of umpteen sports physicals I find this article very good. All that work for such questionable results and at the time I was enduring them they weren’t even aware of the things that really matter, such as the list of things Italy screens for. I think there should be screening and agree the current system needs much work.

  8. icewings27 says:

    The problem with sports physicals, regardless of who is performing them, is that we can never know how many deaths were prevented as a result of excluding someone from participating in a sport.

    Also, excluding everyone with a specific condition, such as cardiac hypertrophy, may result in hundreds of kids being unable to participate who would not have had any negative consequence occur. And, inactivity is unhealthy too, so if a kid is playing videogames instead of football, is that the best option?

    I suspect that allowing chiropractors to do sports physicals won’t make much difference on the “number of deaths we prevented” scoresheet.

  9. ConspicuousCarl says:

    I just seached for chiropractors and our local school district, and these freaks are indeed approved to play doctor with the kids. I think chiropractors and other such whackos are kind of creepy in general (we have one nearby who likes to wander about while offering his nonsense to people at random, as if he were selling oil change coupons). I wasn’t aware that our local school was suggesting it on official documents.

  10. windriven says:

    @icewings27

    “I suspect that allowing chiropractors to do sports physicals won’t make much difference on the “number of deaths we prevented” scoresheet.”

    That is entirely conjectural and beside the point. Allowing incompetent individuals to perform specialist services is the point. Where precisely would you draw the line? We say it is OK for chiros to do sports physicals. Then why shouldn’t they do routine personal physicals? How about diagnosing imminent dissection of the descending aorta?

    Before you say that diagnosing is not the same as performing a physical consider that the purpose of a physical is to determine (diagnose) whether or not the patient has one or more medical conditions that should prevent the individual from engaging in vigorous physical activity.

  11. mattyp says:

    I wouldn’t go to my chiropractor to get reassurance that I don’t have a cardiovascular condition. For that I’d go to my GP. Anything beyond musculoskeletal system is taking the p*ss.

  12. jpmd says:

    One question I have, is what is the incidence of sudden cardiac death among athletes, vs. the incidence in the general population matched for age. If there any reason to test athletes more than those in the marching band?

  13. windriven says:

    @jpmd

    “what is the incidence of sudden cardiac death among athletes, vs. the incidence in the general population matched for age[?]”

    Perhaps not an entirely useful question because you are comparing a tested group (athletes) against an untested group (general population). The better question would be: what is the incidence of sudden cardiac death among athletes versus an age and BMI matched sample from the general population where both sets have received the same screening tests.

    One might speculate that the athletes, tested or not, might do better than a comparably matched control population because the athletes might be expected to enter the study in better cardiopulmonary health. But again, that is pure speculation.

  14. William M. London says:

    And here’s a new article about creating opportunities to serve a role in a patient centered medical home model:

    http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=56186

  15. BillyJoe says:

    Alia,

    “Last Sunday there was also a marathon in Poznań, Poland. Participants were not required to have pre-participation medical examinations, they just signed forms that they are fit enough. There were 6,000 runners. And a 35-year-old man died of a cardiac problem on his 14 km.”

    What cardiac problem did he have?
    And would it have been picked up by a pre-participation medical?

  16. jpmd says:

    windriven, indeed your question may be better, but my point was simply to answer the question of whether we should be screening all children or just athletes (or perhaps none.)

  17. Chris says:

    Actually, the comparison between athletes and marching band members is not exactly apples and oranges. While the performance and halftime show at a high school football game is not as strenuous as the guys in the game, the parade marches require going a couple of miles while playing music. And some of those instruments are heavy.

    But I do have a child who was only in a recreational soccer club. Fortunately we found out about his hypertrophic obstructive cardiomyopathy at a (delayed) well child checkup because of a new heart murmur. We were literally told that he should not go to soccer camp a couple of hours after his echocardiogram (story in previous link).

    Even though the health insurance may not cover the costs, parents should make sure their teenagers get regular check-ups with a real doctor. It would be nice if it included an EKG, which is really not that expensive.

    * He had surgery last spring, and is in continuing cardiac rehab. Because of the HCM he had the specter of “sudden death” hanging over him for nine years with restricted activity. A stress test last fall revealed he was not getting sufficient blood flow after too short of time (the obstruction was blocking flow to the aortic valve), so he was told to not walk the hill between his community college and bus stop. This, plus a couple of 911 calls to our house, is the reason for the surgery. Plus why a couple of months ago we had family echo day to make sure his parents and both siblings did not also have HCM (all were negative). One reason why I have not been a very good blogger.

  18. icewings27 says:

    @windriven – My point was not to say that I think it’s OK for chiropractors to be allowed to assess athletes for serious conditions that would preclude athletic activity. What I meant in my poorly worded comment was that sports physicals, in general, may not be making that much difference in saving lives.

    Example: One of our local physicians, a seemingly healthy man in his 50s, died of cardiac arrest while playing hockey at our rink. Following that tragedy, the hospital donated a defibrillator unit to the rink. Given the number of under-18 hockey players and figure skaters we have here, there is no a good chance it will save a child’s life sometime in the future.

    While we may continue to hope that our childrens doctors (who by the way are usually NOT specialists but family physicians contrary to what you said) will diagnose serious problems, perhaps the best way to save lives on the playing field is to have resuscitation equipment available and to train coaches, refs, etc. how to do perform basic life-saving first aid and CPR.

  19. icewings27 says:

    ^ a good chance, not “no a good chance”.

  20. Scott says:

    I’d be concerned that letting chiropractors do sports physicals – even assuming that they are completely useless – would COST lives. Anything that helps them get more “patients” increases the risk of death by chiropractor-induced stroke.

  21. Chris says:

    Would a chiropractor even recognize the sound of a heart murmur?

  22. BillyJoe says:

    Chris,

    “parents should make sure their teenagers get regular check-ups with a real doctor.”

    Nope.
    You have based this on a personal anecdote.
    That is exactly the wrong reason for promoting a screening test.

  23. lilady says:

    @ Billly Joe:

    Nope, you misread Chris’ post and her link entirely…

    “…..But I do have a child who was only in a recreational soccer club. Fortunately we found out about his hypertrophic obstructive cardiomyopathy at a (delayed) well child checkup because of a new heart murmur. We were literally told that he should not go to soccer camp a couple of hours after his echocardiogram (story in previous link)…..”

    Her son was at the doctor’s office for a “well child checkup” and the doctor found the (new) heart murmur by listening to his heart with a stethoscope.

    You stated:

    “You have based this on a personal anecdote.

    That is exactly the wrong reason for promoting a screening test.”

    Any further testing Chris’ son underwent, after the doctor found the (new) murmur by listening to heart sounds, are not “screening tests”…they were part of the diagnostic work-up.

  24. BillyJoe says:

    Lilady,

    I was responding to this sentence:

    “Even though the health insurance may not cover the costs, parents should make sure their teenagers get regular check-ups with a real doctor. It would be nice if it included an EKG, which is really not that expensive.”

    Chris based this on the personal anecdote about her son, or so it seemed to me, because it followed immediately after her anecdote.
    Is there evidence that regular teenager check ups are cost benefit effective?
    Is there evidence that routine ECGs in teenagers (or adults) are cost benefit effective?
    They should not be routinely done, unless and until the evidence shows clear benefit.

  25. Chris says:

    BillyJoe, that is a good point. Though I think a regular checkup, even without the EKG, is useful for teenagers for several other reasons (like reassuring my daughter who tends to be a germaphobe hypochondriac). But that is wavering off topic.

    The real issue that athletic exams should at least be done by someone who has a stethoscope and knows how to use it. I sincerely doubt any chiropractor would recognize a heart murmur.

  26. Chris says:

    By the way, HCM occurs in about one in a thousand people (and on the more militant sites it is one in five hundred, most of them without obstruction). Add that to the numbers of other genetic cardiac conditions there may be a reason to have a teenager seen for a checkup every other year or so where the only high tech equipment are a stethoscope and a blood pressure cuff. It may even catch an abnormal pulse. I personally think that it would have helped my journey through puberty. Okay, end of off-topic opinions.

    But from what I can find, there is no evidence for routine EKG and echocardiograms for athletes. Especially when there are too many false positives.

    As an aside, googling for “heart screening teenager” brings up lots of activists for global screening of athletes (like the youtube video titled “Teenage Athletes are Dying”). The linked to article in previous paragraph was an anomaly. Though I did not see any that recommended going to a chiropractor.

  27. BillyJoe says:

    Chris,

    Yes, my daughter’s pulsus bigeminus could have been picked up by a doctor using a stethoscope but, as it was, it was picked up by my other daughter using her mobile phone.
    I sort of have a soft spot for the second method. :)

  28. Chris says:

    But it could have been caught a year or two earlier! And your anecdote relies a wee bit on luck, and having a phone with a particular app.

    There are multiple reasons why well child check ups should extend to teenagers, including getting them a Tdap booster. That is perhaps a subject for the family doctor and the pediatricians who contribute to this blog.

  29. BillyJoe says:

    Yes, I used the smiley for a reason. :)
    BTW, you have a good memory for postings on previous threads.

  30. mousethatroared says:

    Oh well, the agency with the non-memorable accronym recommends at least screening for depressive disorders and obesity and nutritional health in teens (there may be more, their website….ugh) I just don’t see why docs wouldn’t listen to heart, breathing and get blood pressure too, which is standard for office visits. Sure we could say that there’s no evidence they should be done, but I don’t see any recommendations that they shouldn’t be done either. cost/risk seem like they would be extremely low.

  31. Chris Repetsky says:

    The state where I live allows DCs to perform school physicals, but a lot of the school districts around here mandate that the exam be performed by an MD or DO only. For one particular school, the bottom of the physical form even said “Examination cannot be performed by a Chiropractor”. One of the local town Chiros used to take those forms from the patient, painstakingly copy all the information from the school form to his own generic physical forms (without the disclaimer listed, of course), then sign his name under “Examining Physician” without denoting his credentials.

    Shockingly, the school still accepted his generic forms and didn’t question it.

  32. mousethatroared says:

    CR “Shockingly, the school still accepted his generic forms and didn’t question it.”

    I wonder if this a choice on the schools part or just an oversight? Perhaps a letter to the school or board politely noting the oversight and the possibly legal ramifications in the event that something untoward should happen might rectify the situation.

  33. Chris Repetsky says:

    Knowing this particular district, it was an oversight on their part.

    I did however write to both the school and the Chiro Board about this particular “doctor”. As you might predict, nothing was done.

  34. mousethatroared says:

    @Chris – well good on you for writing those letters! Bummer that nothing happened, but who knows, maybe those letters will be seeds that sprout when the situation changes a bit.

  35. DWATC says:

    As an ATC, chiropractors annoy the hell out of me. We have one that came to town recently that advertises knowledge in sports medicine. My athletes go to him for frequent adjustments and “treatment”, yet months later end up coming to me asking why they’re not getting better or ask advice. I tend to simply explain why manipulations make them feel better and suggest physical therapy, but say if they’d like to go to them and their parents are okay with wasting the money, they can. I refuse to refer my athletes to them. When I first started, I sent one my athletes to a chiropractor because he gives free exams to student-athletes, but specifically told him not to let the chiro “pop” his neck, and guess what he did?….Anyway, to be honest, I think chiropractors could do the orthopaedic portion of the pre-participation exams, but not the general medical.

    As far as sudden death is concerned, preventative measures are extremely difficult. Our key role is reacting appropriately when an episode occurs, like recognizing the situation, recognizing the symptoms during activity in season before an episode occurs, getting an AED on them within 2 minutes of collapse, etc. Luckily, I haven’t encountered anything yet, and hopefully never will. Generally if there is concern, I may do my own progressive exhaustive testing under close supervision to gauge limits, and if I feel they can’t participate I’ll send them back to the doc with restriction recommendations. It’d be insane to ask parents to pay for pre-screening ECGs. As a parent myself, I’d love to take every precaution, but if the need isn’t there, it’s a waste. Recognizing the necessity of the tests is important and most parents don’t have that ability. Some physicians take advantage of that in particular.

    While I’m here and physicians are present… If one works with an ATC or maybe interacts with one or more, Is there anything in particular you would like out of us to make the transition more smooth or something that can make our interaction much easier? Are we doing anything or not doing something that annoys you? What more do we need to do?

  36. BillyJoe says:

    Michele,

    “Sure we could say that there’s no evidence they should be done, but I don’t see any recommendations that they shouldn’t be done either”

    But this is a science-based medical blog.
    Is your medicine science based or is it not.
    You really can’t have it both ways.

  37. BillyJoe says:

    …put it this way:

    A middle aged man comes in with an ankle strain. The doc hasn’t seen him before. What else should he do besides dealing with his ankle? Take his BP, his PR, listen to his heart, do a urinalysis, check his retinas, enquire about family history of bowel and prostate cancer, ask about work stresses, marital issues?
    Surely this should be evidence based.
    And surely there must be clear evidence of benefit.

  38. mousethatroared says:

    But BillyJoe, what is the starting point for making decisions about which observations a doctor should make. Do we have to provide scientific evidence on whether a doctor should shake your hand or not? How about look at you versus the computer when asking a question? Listening to the heart and lungs and taking blood pressure have been standard for physicals as long as I remember. Do we need evidence to change the status quo or do we need evidence to do anything?

  39. Harriet Hall says:

    Taking blood pressures routinely has proven value. Listening to heart and lungs as a routine doesn’t. We are moving more and more towards eliminating screening exams like pelvic exams and concentrating on proven preventive measures. See http://www.sciencebasedmedicine.org/index.php/questioning-the-annual-pelvic-exam/

  40. mousethatroared says:

    @Harriet Hall – maybe this is a stupid question, but is there any merit to the idea that listening to all those normal lung and heart sounds keeps the doctor in practice enough that they can more easily distinguish abnormal sounds?

    I’ve never listened to either, so maybe this is a silly idea.

  41. Harriet Hall says:

    @mousethatroared: “is there any merit to the idea that listening to all those normal lung and heart sounds keeps the doctor in practice enough that they can more easily distinguish abnormal sounds?”

    No. Refresher courses in listening to patients with abnormalities would probably be more helpful. In fact, listening to one normal patient after another breeds a sense of complacency and might be expected to interfere with picking up the occasional subtle abnormality. Perfunctory listening to heart and lungs is not productive compared to a directed exam with maneuvers to elicit signs of disease.

  42. mousethatroared says:

    Okay, I can see that. Thanks!

  43. BillyJoe says:

    Michele: “Listening to the heart and lungs and taking blood pressure have been standard for physicals as long as I remember.”
    Harriet: “Taking blood pressures routinely has proven value. Listening to heart and lungs as a routine doesn’t”

    Science-based medicine in action (:

  44. Chris says:

    I am also going “Huh?”. Because my son’s life threatening heart condition was hinted at by a stethoscope.

    Dr. Hall, you seem to be saying that heart murmurs are not significant.

  45. Harriet Hall says:

    @ Chris,

    Billy Joe had asked about the exam of a middle-aged man. Heart murmurs are usually due to either a congenital condition that would have already been picked up in childhood or to a condition with symptoms or other findings that would prompt a doctor to do a directed diagnostic exam. I know of no evidence that listening to an asymptomatic middle-aged man’s heart and lungs as a routine screening test does more good than harm. Even routine auscultation of children is problematic, because there are so-called “innocent murmurs” that sometimes lead to a lot of worry and unnecessary tests. We run into the same dilemma with other screening tests: sometimes an unexpected finding can save a life, but all too often an incidentaloma leads to a wild goose chase or a finding is one where early detection and treatment does not improve the eventual outcome.

    This is one of my pet peeves. Every time I see a doctor, he applies the stethoscope in 2 or 4 spots to listen to my lungs and one or two spots to listen to my heart, without looking for the PMI or doing any special maneuvers. If I really had a problem, that kind of superficial exam would be inadequate. It’s like it’s a “hands-on” ritual. I would be quite happy to never be auscultated again unless I developed new signs or symptoms suggestive of heart or lung disease.

  46. mousethatroared says:

    HH “Even routine auscultation of children is problematic, because there are so-called “innocent murmurs” that sometimes lead to a lot of worry and unnecessary tests. We run into the same dilemma with other screening tests: sometimes an unexpected finding can save a life, but all too often an incidentaloma leads to a wild goose chase or a finding is one where early detection and treatment does not improve the eventual outcome.”

    I haven’t read the research on listening to the heart in children, so I don’t know the finding are, but here is the thing that concerns. We have Chris’ anecdote, which, to me, is strong evidence that the doctor listening to the heart saved a child life, at least in a rare case. We have the cost of the actual procedure, negligible, and the cost of false positive.

    My personal anecdote, my son had some cardiology testing that resulted in a false positive that was subsequently resolved by a pediatric cardiologist consultation. I would guess that the false positives may cost some money and some anxiety (although the anxiety is subjective and can depend upon how the medical establishment presents the findings and follow up) But unless we have evidence that the false positives result in an equal or larger number of deaths than the lives possibly saved, then I have to see the numbers to support recommendations.

    I looked at the numbers and explainations in the new mammography recommendations and I was in agreement, but it’s hard for me to imagine false positives for pediatric heart conditions adding up the same.

    I actually looked for USPSTF recommendations on this but didn’t find any for pediatrics. Doesn’t mean they are not there, that web site is not a paragon of virtuous information design.

  47. BillyJoe says:

    Michele,

    “I have to see the numbers to support recommendations.”

    You have hit the nail on the head.
    You have to see the numbers first to support any recommendation for a screening test.

    “it’s hard for me to imagine false positives for pediatric heart conditions adding up the same.”

    And that’s a bad miss.
    It’s hard for people to imagine that prostate screening wouldn’t be a useful thing to do, yet the numbers do not support it.

  48. Harriet Hall says:

    @mouse,

    Your anecdote is about false positive cardiology testing. I’m guessing that was not a screening test, but a diagnostic test ordered because a doctor had reason to suspect a problem.

    The USPSTF doesn’t have any recommendations about auscultation in children or adults. Absence of recommendations usually means that they didn’t think it was even worthwhile considering it as a preventive screening measure. They don’t mention chest percussion either http://www.rnceus.com/resp/respperc.html No one has ever suggested chest percussion as a screening test for the general population, although someone could probably come up with an anecdote where it had detected an unsuspected problem and saved a life.

    Even when a stethoscope discovers a significant finding, that finding might have been discovered anyway at a later date, and it would have to be shown that earlier detection improved outcomes.

  49. Chris says:

    In short: it is complicated. (note I just finished reading Heart 411, which has examples of over/aggressive treatment)

    But in general, not something chiropractors are even trained about.

  50. mousethatroared says:

    BillyJoe – We now have recommendation on prostate cancer. I didn’t argue with any documented recommendations. The question is, what do you do in absence of recommendations? No you default to doing nothing or do you default to making a scientically plausible, but not as of yet fully researched recommendation?

    I’m perfectly fine with Harriet Hall putting forth arguments on what approach has the most plausibility based on what we know. But it sounds like you are saying we should do no testing or screening until we have solid evidence and agency recommended guidelines on those tests. I’m not buying that.

  51. mousethatroared says:

    BillyJoe “And that’s a bad miss.
    It’s hard for people to imagine that prostate screening wouldn’t be a useful thing to do, yet the numbers do not support it.”

    And no, I don’t think it’s a bad miss. Because I’m not talking about arguing with the numbers, I’m talking about making a decision in the absence of data.

  52. Harriet Hall says:

    There are no data suggesting that we screen all prepubertal girls with tests for gonorrhea, although it is plausible that it could pick up an occasional case of sexual abuse and save a life. All sorts of recommendations might be suggested based on different people’s opinions of what is plausible and advisable. The USPSTF has tried to provide comprehensive guidelines for preventive medicine, and I can’t think of anything they have missed that is plausible enough to implement for screening the general public before we have evidence from research. Can you?

  53. mousethatroared says:

    Harriet Hall – That’s not fair, that web site is awful, it’s deeply emotionally painful for me just to attempt to read a guideline, much less research what they may or may not have covered. :)

    I’m just wondering, though. I accept the correction that listen to lungs is not standard. But we both seem to agree that listening to the heart has been a standard part of physical exams.

    Correct me if I’m wrong, but it seems that we both acknowledge that listening to a child’s heart may be useful at some point (as an infant, at least) It also seems to me that while a child is growing their heart status may change. So maybe it’s useful to listen to their heart at another point.

    If listening to the heart (if it has been standard) in the past has caused harm due to risks or discimfort during the process or false positives that result in harm to the patient, then why didn’t the USPSTF issue guideline recommending against the procedure?

  54. mousethatroared says:

    HH – By the way, you are correct, my son’s false positive was not as a result of screening, it was a EKG that was recommended based on risk factors. I wasn’t trying to recommend screening based on that anecdote, only suggest that the false positive wasn’t a huge trauma. All false positive are not created equal, is what I was saying.

  55. Harriet Hall says:

    I can’t second-guess the USPSTF, but they often say there is insufficient evidence to recommend either for or against a screening test; I think auscultation is squarely in that category. I don’t know of any evidence that it’s harmful; I mainly think that in most cases auscultating asymptomatic adults is a waste of time and a symbolic ritual. I would guess that if a proper study were done it would show that screening children with auscultation is worthwhile, but without studies we can’t specify when or how often it might be indicated. My unsupported opinion is that it should be part of the newborn exam and repeated at least a couple of times as the child grows, but not on every visit.

  56. Chris says:

    Dr. Hall:

    My unsupported opinion is that it should be part of the newborn exam and repeated at least a couple of times as the child grows, but not on every visit.

    Like at times when non-influenza vaccines are scheduled. My son’s heart murmur was heard when he got his Td booster at age fourteen.

  57. BillyJoe says:

    Michele,

    “But it sounds like you are saying we should do no testing or screening until we have solid evidence and agency recommended guidelines on those tests. I’m not buying that.”

    I’m saying that screening tests should not be done without clear evidence of benefit.
    If you are not buying that, then you are not buying science-based medicine.

    And, look at it from a practical point of view. There are any number of examinations and tests that a doctor could perform as a routine on his patients, and they all take time. They could take so much time that they couldn’t possibly all be done on every patient. So what better than to demand an evidence base for what doctors do as a routine. Sift the wheat from the chaff. Otherwise, mainstream medicine is no better than CAM, except for plausibility. But plausibility is not enough for a screening test. Most things that are plausible don’t pan out in practice. Stick with what has been shown to be beneficial.

    I see this as one of the main lessons of science-based medicine.

  58. mousethatroared says:

    BillyJoe – If you make that argument for screening, one could make a similar argument for testing and treatment. Do you?

  59. mousethatroared says:

    HH – Your conclusion sounds reasonable to me. Thanks for your thoughts.

  60. BillyJoe says:

    Michele,

    Yes, of course.
    I reject any test and treatment without evidence of benefit. Don’t you?
    Otherwise what are we doing here but just pissing around.

    As I’ve said before, it okay to be all science minded about medicine when it comes to refuting CAM use by others but, if you throw it all to the wind when it comes around to your own health and the use of mainstream medicine, how serious can you really be?

    As someone else has said, there is only science-based medicine and non science-based medicine.
    I really have no interest in the second kind.

    BTW, I don’t see how anything Harriet has said is any different from what I’ve said, but perhaps I’ve missed something.

  61. BillyJoe says:

    ….oops I must have missed this bit:

    Harriet: “My unsupported opinion is that it should be part of the newborn exam and repeated at least a couple of times as the child grows, but not on every visit.”

    Oh well, nobody’s perfect. (:

  62. mousethatroared says:

    BillyJoe – did see what I was getting at when you saw HH’s post or should I keep explaining?

  63. BillyJoe says:

    If Harriet is doing things unsupported by evidence, I assume she is doing them because they are plausibly of benefit but without evidence as yet of benefit. The problem is where do you stop. But provided doing things which are very plausibly beneficial but are unsupported by evidence takes up minimal time, it could be justified.
    But there is a danger as illustrated by prostate screening: it’s hard stop a screening test once evidence shows it to be of no benefit.

  64. mousethatroared says:

    BillyJoe – I think you have an misperception about how much “good” evidence there is. There are many under researched conditions and groups in medicine. This leaves you with the question of what do you do when you don’t have good evidence.

    Doing nothing is just as arbitrary a solution taking vit C. I prefer an approach that says you use the best available evidence, including plausibility, to test, diagnoses and balance risk/benefit in treatment. Sometimes that results in doing nothing, sometimes that results in an intervention.

    If that approach leads to a CAM intervention, then so be it. I’m not opposed to many CAM treatments, they just don’t happen to have the best available evidence, plausibility, risk, benefit profile in any condition I’ve had or seen in my loved ones. A CAM practitioner wouldn’t be my prefered option because they have shown lower reliability in knowing the best available evidence, plausibility and analyzing risk/benefit than conventional doctors.

    And you can knock off the “Refuting CAM in others, but throw it to the wind when it come to your health” argument. I am not a big refuter (is that a word?) of CAM, unless the CAM clearly defys my above principle AND is being sold on misrepresentations or performed on minors or those not able to care for themselves.

  65. BillyJoe says:

    Michele,

    I don’t actually separate mainstream from CAM, or CAM from mainstream, except that CAM almost always turns out to be useless, whereas mainstream treatments often do not. My categories are science-based medicine and non science-based medicine. And my attitude is one of extreme scepticism. SBM = PP + evidence and I think both components are required. There are too many treatments and tests that seem plausible but that don’t pan out once the evidence is in, so look for the evidence first. And evidence without plausibility suggests the evidence is flawed, so look for the flaws in the evidence.

  66. mousethatroared says:

    BillyJoe – So tell me how your system works for someone with a serious and under-researched condition?

  67. BillyJoe says:

    Michele – by doing the research first.
    I will refer you again to the prostate screening debacle. The enormous waste in time money and manpower that has already occurred, and will continue to occur into the foreseeable future despite the now available contrary evidence, provides an object lesson on how not to practice medicine.

  68. Harriet Hall says:

    The USPSTF frequently states there is not enough evidence to make recommendations for or against a screening test for the general population, and in those cases as well as in the cases where the question hasn’t even been addressed by any research, decisions are left up to the individual doctor for individual cases. The practice of medicine is messy and we don’t always have evidence to go on, but we still have to act. Sometimes the best we can do is to act on an educated guess. We must try to remember that our guesses could be wrong, and we must be ready to alter our practices when evidence becomes available. IMHO it would be foolish for a doctor to omit auscultation on a newborn exam just because there is no evidence that it results in better outcomes. Another consideration is that omitting it might result in a malpractice suit.

    A case in point: I was taught that the newborn exam is the only time in a patient’s life when the kidneys can be palpated through the abdomen, offering a unique opportunity to detect the rare case of a missing kidney or a horseshoe kidney. I don’t have any evidence that checking for kidneys improves health outcomes. I would stop doing it if evidence showed it did more harm than good. Meanwhile, I have to decide whether to check or not check, and I elect to check.

  69. mousethatroared says:

    BillyJoe – I don’t think you are seing the flaw in your reasoning. You have to weigh the risks/benefits to the patient of any actions or inaction. You are weighing the risk to society of something like the “prostrate screening debacle” happening more heavily than the possible risk of action or inaction to the patient with a serious condition.

    I agree with HH’s approach. Reading the other blogger’s here, I think their approaches are similar to her’s…due to experience with my son, I look for how doctors approach a patient’s condition when there is a lack of good evidence I haven’t seen anything that concerns me in that regard from the articles I’ve read.

  70. mousethatroared says:

    Harriet Hall – Thanks for the summary of your approach. I think you are much better at communicating these things than I am.

  71. BillyJoe says:

    Michele,

    I understand what Harriet is saying. If it’s a simple activity that doesn’t take up much time, effort, and manpower ( how long could it take to listen to the heart or palpate a kidney) and if it is plausible, I don’t really have a problem. But you have to careful that you don’t end up wasting lots of that precious time, effort, and manpower that is better employed doing activities that are evidence based.

    Just this week I read an article that slams routine health checks on healthy people. There is no evidence that such activities are beneficial and save lives. And routine health checks are very time consuming and expensive if you add in the routine tests that are done as part of a routine medical and dealing with the false positives. The article reinforced my decision many years ago not to have routine medical examinations and tests.

    But you have clarified my thinking here and thanks for that.
    I appreciate docs who work in the best interest of their individual patients with sometimes limited evidence about what they should do. I hope I find one like that if I’m ever unfortunate enough to need any medical assistance. Someone like Harriet or nybgrus, for example.

  72. Harriet Hall says:

    @BillyJoe,

    Here’s another “article that slams routine health checks on healthy people”:

    http://www.sciencebasedmedicine.org/index.php/re-thinking-the-annual-physical/

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