A Good H&P, a Dwindling Skill
Having done medical school in the era (circa early 60’s) before ultrasounds, CT scans, MRIs, tumor markers and the like, I was nevertheless skeptical when our faculty kept assuring us that a good, thorough careful history could elicit an accurate diagnosis 80% of the time and a similarly done physical exam could get the results up to 90%, This would be all without lab or X-ray tests.
I remained on a slow learning curve through the first two decades of practice, never fully enlisting this sage advice and too often falling back on the investigative crutches. That orientation started to reverse after my first overseas mission tour in the early 80’s. At a camp of thirty thousand Laotian refugees on the Mekong River in northern Thailand, I was the lead medical officer on the International Rescue Committee’s team. Our lab support provided only hematocrits, dip stick urines and stool microscopy. The hospital in the nearest town (10 klicks away) could do chest and limb skeletal X-rays.
Beyond that a history through an interpreter and as much of a physical we could do in cramped, crowded quarters underlay all clinical decisions. Remarkably the overall care for the refugees was excellent, all things considered. Having an excellent medical and nursing staff contributed. Also useful was doing serial, repetitive histories and physicals to confirm and flesh out the diagnoses.
When I returned home after three months the mind set of valuing and relying heavily on good histories and physicals more or less stayed with me. I came to resist the habit of routinely ordering lots of front end technology. The lessons of 1960s medical teaching began finally to make increasing sense. Still, in generalizing this approach there are some problems.
First, present economics compel changes in medical record keeping and in provider-patient interaction that limit the time for doing a effective history and physical. As well, the training in doing thorough exams are just not taught in medical school, at least compared to my educational experience. I say this from my having taught Intro to Clinical Medicine to 2nd year students for ten years.
See me as a dinosaur, but I firmly believe solid training and ongoing performance of careful, thorough H&P leads to better diagnoses, save money and enlist skills a physican will always have when technology is not there.