A bit of good news for a change: a “Perspective” article in the New England Journal of Medicine describes how point-of-care ultrasound devices are being integrated into medical education. The wonders of modern medical technology are akin to science fiction. We don’t yet have a tricorder like “Bones” McCoy uses on Star Trek, but we are heading in that direction, and the new handheld ultrasound devices are a promising development.
The stethoscope has become iconic, a symbol of medical expertise draped proudly around the neck by doctors and other medical personnel. Before it was invented, doctors could only try to listen to a patient’s heart by direct application of ear to chest. In 1816, Laennec interposed a tube of rolled paper between ear and chest, and the stethoscope was born. It quickly became an essential tool, allowing us to hear the distinctive murmurs produced by different heart valve abnormalities, to take blood pressures, to detect the wheezing of asthma or the collapse of a lung , to hear the bruits caused by atherosclerotic narrowing of blood vessels, to detect intestinal obstructions by listening for borborygmi (I love that onomatopoeic word!).
The stethoscope allows us to hear sounds produced by the body, but sound also allows us to see inside the body. Diagnostic ultrasound has a multitude of uses. With prenatal sonograms, we can determine the sex of a fetus, watch it suck its thumb, and even take its picture for the family album. With echocardiography we can evaluate heart valves, see fluid accumulation in the pericardium, observe the thickness and motion of the heart wall, and even quantify the efficiency of the pumping process. Ultrasound lets us see clots in blood vessels and stones in the gallbladder, evaluate abdominal organs, detect cysts, screen for carotid artery narrowing and abdominal aortic aneurysms, and guide needles into the body for therapeutic and diagnostic purposes. (more…)
Two weeks ago I wrote about the demise of the traditional annual physical for healthy adults who have no symptoms.
The First Step: Identifying a Symptom
People who do have symptoms should see a doctor. They should have appropriate evaluations that may or may not include a partial or complete physical exam. One problem is that people may not be able to decide what qualifies as a significant symptom. Could the heartburn actually be a heart attack? Is the fatigue a normal result of exertion, or could it be a sign of something serious? Could my headache be a sign of brain tumor, or should I just take an aspirin? My spouse says I’ve been snoring more: could that be a sign of sleep apnea? What if I just “don’t feel right”?
This is a real dilemma, because minor transient symptoms are a normal part of life. Some of them are due to trivial conditions that spontaneously resolve; some are sensations due to the normal functioning of the body. Some people are more aware of these sensations than others. Paying attention to them tends to make them worse. Some people barely let these minor sensations intrude on conscious thought; others fixate on them and obsess about them. There is a spectrum of human reactions ranging from the stoic denier to the hypochondriac. (more…)
A new article in the Journal of Women’s Health by Westhoff, Jones, and Guiahi asks “Do New Guidelines and Technology Make the Routine Pelvic Examination Obsolete?”
The pelvic exam consists of two main components: the insertion of a speculum to visualize the cervix and the bimanual exam where the practitioner inserts two fingers into the vagina and puts the other hand on the abdomen to palpate the uterus and ovaries. The rationales for a pelvic exam in asymptomatic women boil down to these:
- Screening for Chlamydia and gonorrhea
- Evaluation before prescribing hormonal contraceptives
- Screening for cervical cancer
- Early detection of ovarian cancer
None of these are supported by the evidence. Eliminating bimanual exams and limiting speculum exams in asymptomatic patients would reduce costs without reducing health benefits, allowing for better use of resources for services of proven benefit. Pelvic exams are necessary only for symptomatic patients and for follow-up of known abnormalities. (more…)