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June 9, 2011

Medical education must get back to basics, prof says

Basil Zitelli

Basil Zitelli

As part of the Provost’s Inaugural Lecture series, pediatrics professor Basil J. Zitelli, who was named the Edmund R. McClusky Endowed Chair in Pediatric Education, celebrated his appointment by presenting a May 26 talk, “Back to the Future, with Apologies to Sir William Osler.”

Osler, a co-founder of the Johns Hopkins medical school, is considered one of the fathers of modern medical education.

A proponent of teaching medical students at patients’ bedsides, Osler is credited with establishing the medical residency system.

The advent of advanced medical technologies has increased access to information, improved doctors’ efficiency and enhanced patient safety, Zitelli said. Doctors have access to iPods, iPads, computers and a wide range of scans, blood tests and even genetic tests to help them diagnose and treat patients. “We depend upon technology and our patients and families expect the very best. They expect us to use technology. They sometimes actually come in and demand it,” he said.

“The question is, has technology produced the best health care system?”

Many people believe so, yet technology carries with it a downside as well. Citing one study that found 12,000 deaths from unnecessary surgeries, 80,000 from infections and 106,000 from the adverse effects of medication, Zitelli noted that some of those deaths could have been due to the use or misuse of technology.

The cascade effect

One risk associated with technology is the “cascade effect” — a chain of events initiated by an unnecessary test that has caught a doctor’s attention. Zitelli cited the case of a 12-year-old boy who complained of headaches. The boy’s physician referred him to an optometrist, who found a minor refractive error. A skull X-ray was normal, but a CT scan found a minor abnormality. That discovery caused the family anxiety amid fear that it could be a tumor. Ultimately an MRI showed the same abnormality, heightening their fear.

When the boy was referred to Zitelli’s clinic, a careful history and physical exam showed the headaches weren’t progressive, and there was no family history of migraines. The boy had been under stress due to some problems at school. As it turns out, the abnormality was a benign cyst. Furthermore, by the time the boy was seen in the clinic, his headaches had disappeared.

Another example is fetal monitoring, which can cause anxiety for women in labor, Zitelli said. If anxiety slows labor, medications can speed it up, but those can have an adverse effect on both the infant and the mother and can raise the risk for a Caesarean section. He said studies have shown that in most cases, the use of fetal monitoring didn’t improve outcomes.

Lab tests: What’s normal?

Shotgun testing also is a temptation, Zitelli noted, saying that it’s simple for doctors to order a set of tests, rather than just the single test they really want.

However, when it comes to test results, errors are built into the statistical definition of normal, Zitelli said, explaining that norms are defined as two standard deviations from the mean in a healthy population.

That means one in 20, or 5 percent of normal results, will be considered as abnormal, he said. “This is purely a statistical definition, and does not necessarily mean that the patient who had that particular lab test result is, in fact, abnormal.”

As the number of tests increases, the probability of at least one abnormal result rises as well. “If a single test was done, there’s a 5 percent chance that it will be abnormal. If you have 12 tests that are done — not an unusual number of tests — there’s a 46 percent chance that at least one of those tests will be abnormal. And if you have 100 tests done — again, that’s not an unreasonable number of tests for patients who have some complex illnesses admitted to the hospital — you have a virtual certainty that at least one of those tests will be considered abnormal,” he said.

Rather than relying solely on test results, doctors need to evaluate testing. “We have to know what we’re doing and put the results in the context of the particular patient,” Zitelli said. “Some of the tests we do may be out of the range of normal but not necessarily be abnormal for the patient.”

Zitelli noted that technologies such as electronic medical records and computerized physician order entry (CPOE) significantly cut medical errors, but the introduction of a new technology also has its tradeoffs, sometimes producing other errors.

He said there were growing pains when these systems first were put in place at Children’s Hospital. Test results sometimes were lost in cyberspace and communication issues had to be resolved. Learning the system and the proper syntax took time, too, he said. “Any system, any technology, requires repeated evaluation and refinement,” he cautioned.

Overreliance on technology can delay diagnosis and treatment when technology is not available. How can doctors treat a patient when the computer is down or the MRI machine isn’t working? What happens when unexpected results come back from the lab?

Back to the basics

Citing the term coined by Herbert L. Fred in a medical journal editorial, Zitelli cautioned against “technologic tenesmus” — the uncontrollable urge to rely on sophisticated medical gadgetry for diagnosis, almost to the exclusion of a good history and physical exam.

“It preys upon the ill-trained, the ill-informed and those who are looking for shortcuts,” Zitelli said.

To combat the downside of technology, Zitelli urged a return to the basics. “I think we should utilize the history and physical exam to formulate the diagnosis, then use technology to verify it,” he said.

“History and physical exam are noninvasive and are by far the most cost-effective.”

Overreliance on technology also can threaten doctor-patient relationships, he said. If doctors trade the practice of traditional medicine that includes laying on of hands and sitting at a patient’s bedside for sitting behind a large desk with a computer and a sheaf of test results, they run the risk of alienating their patients and missing crucial information that could be gained simply by listening.

“Listening is a form of respect,” he said, citing Osler’s assertion that “listening is unspoken caring.”

Reliance on lab tests and technology has reduced emphasis on good physical examinations, he said. “We are getting further and further away from our clinical skills.”

Recent studies showed that a significant portion of residents from U.S. medical schools could not perform a complete standardized abdominal exam accurately, he noted. Fewer than half used the traditional four-part approach of inspection, palpation, percussion and auscultation — visually observing, feeling, causing vibrations to produce a sound and listening.

Another study of pediatricians from academic institutions found that 54 percent reported making diagnostic errors once or twice a month and 45 percent reported making an error that harmed the patient. “When looking at those errors, the diagnostic error generally was the failure to get information through history, physical examination or adequate chart review,” Zitelli said, adding, “Perhaps Dr. Osler was correct when he said medicine is learned at the bedside and not in the classroom.”

Zitelli noted that medical students typically enjoy bedside rounds and that patients’ families typically view them positively, particularly when they’re encouraged to ask questions and when the visits are conducted in a sensitive and respectful manner.

Students gain expertise and confidence by honing their powers of observation and physical examination skills, as well as by observing both normal and abnormal findings, he said.

Improving med students’ skills

Zitelli said he challenges his students to play a game with themselves, selecting one aspect of the physical examination to pay particular attention to for a time. One week it may be “second heart sound week,” in which students pay special attention to what they hear when listening to the patient’s heartbeat; the next will be “nasal turbinate” week in which students more closely observe patients’ upper respiratory tracts, for example.

He also challenges them to find something in their examination that the resident or attending physician hasn’t documented.

Or, when demonstrating infant physical examinations, Zitelli said he sometimes asks his students to tell him what they see without touching the patient. “When challenged in that way, they are able to do a phenomenal physical examination, just by observation.”

All these techniques aim to improve students’ powers of observation, he said. “It’s important when walking into the room their powers of observation are tuned up,” he said.

“I believe that technology provides a magnificent means of verifying diagnosis, but the misuse of technology may lead to errors and the cascade effect and may interfere with patient-physician relationship and lead to estrangement.

“The history and physical examination remain the most efficient and cost-effective means of making a diagnosis. The history and physical examination re-establishes the needed contact between the physician and the patient, particularly with the laying on of hands,” he said.

“Accurate physical diagnosis demands that we enhance the powers of observation through teaching and continued lifelong practice. Through teaching we can share the joy of the clinical experience with the students and residents,” he concluded.

“I believe Dr. Osler was correct when he said that the whole art of medicine is observation and, as the old motto goes, that to educate the eye to see, the ear to hear and the finger to feel takes time. And to make a beginning to start a student on the right path is all that we can do.”

—Kimberly K. Barlow

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