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| EDITORIAL |
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| Year : 2015 | Volume
: 1
| Issue : 1 | Page : 7-8 |
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Bedside evaluation in the era of imaging
Shyam S Kothari
Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| Date of Web Publication | 22-May-2015 |
Correspondence Address:
Dr. Shyam S Kothari
All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2395-5414.157553
How to cite this article:
Kothari SS. Bedside evaluation in the era of imaging. J Pract Cardiovasc Sci 2015;1:7-8 |
Now that brain natriuretic peptide testing and echocardiography can detect left ventricular dysfunction more accurately, that computed tomography angiogram can show coronary arteries reliably, and magnetic resonance imaging can identify ischemia and hibernation in one go; is there any role for the rituals of bedside evaluation? This lengthy question can have a short simile-now that cars for visually handicapped have been innovated in which you do not need to see or use hands to drive, is there any point in keeping older versions that require hands, eyes, and mind to drive? This absurd analogy might not convince many, but the declining importance of the bedside evaluation in contemporary medical, and especially cardiology practice calls for a pause and reflection on the issue.
The tremendous progress in the medical field is largely the product of progress in technology, imaging and in other fields that have made the diagnosis and treatment of diseases so effective. No doctor in today's medical field can afford to be a luddite (a person with anti-technology mindset).
However, the appropriate use of technology also needs a mindset that is rooted in the critical question of a particular patient and his welfare, just the mindset that engages and expands in the bedside evaluation. This is akin to the compass required to navigate fully loaded high-tech ship in an unknown territory.
Bedside evaluation simply consists of clinical history, physical examination and perhaps simple tests that can be done without complicated gadgets (bedside ultrasound will be part of bedside exam soon). Essentially it reflects the involvement of the doctor in the simple question of what ails you and what best can be done for you under the circumstances? This simple approach, of late, has become so complicated, like many other simple things in modern life that we have started asking as if progress in technology and bedside evaluation are mutually exclusive exercises.
The slow and steady neglect of the bedside evaluation is responsible for raising the costs of medical care, eroding the trust of doctor patient relationship, robbing the shine of medical practice and degrading it to robotic automatism. Listed below are some reasons for continuing importance of the bedside evaluation even in modern medical practice. These and others are well articulated more recently. [1],[2],[3]
- As stated above, a mind engaged in the bedside evaluation reflects a mind eager in understanding and solving that particular patient's problems. This is the most important thing that a patient can ask for, and all other benefits also stem for this
- Targeted care guided by bedside evaluation reduces costs, unnecessary anxiety and pain of multiple procedures thus minimizing interference in patient's life. Unimaginative use of imaging and other tests only occasionally results in a surprise diagnosis: However, mostly result in redundant overlapping information, incidentalomas, and expense (every cardiologist can recount in his own environment examples of needless liver biopsy that could have been avoided by a jugular venous pressure examination, an inadvertent thrombolytic therapy that could have been prevented by examining peripheral pulse, and a missed opportunity of preventing the stroke if the history of minor transient ischemic attack was understood correctly by unhurried bedside evaluation and so on)
- It increases the trust in doctor patient relationship and thereby hopefully reduces the practice of defensive medicine, which is a byproduct of the modern medicine practice style
- It makes the teaching and learning medicine much more effective. The loss of bedside exercise is perceived as loss of something worthwhile by teachers as well as students [4]
- The simple bedside evaluation can often be repeated and thus help in monitoring the trends in patient's clinical status and aid in the therapeutic decisions.
It is indeed worrisome that physicians even in the areas of the world that doesn't have the fancied technologies (as in most parts of world actually) are so prepared to abandon bedside evaluation based on the reports and recommendations from the western world irrespective of their local ground realities.
However as with all rituals, the ritual of the bedside evaluation also needs to transform itself with time. The arcane, unnecessary or wrong precepts must be deleted and replaced by newer signs guided, verified or modified by the newer technology. Observation will never be obsolete. [5] Bedside evaluation must also continue to correct itself and discover newer paradigms. The progress in medicine is the ever widening circle of influence of medicine into the lives of people, and the bedside evaluation is the center of that circle. Therefore, bedside evaluation will never be obsolete.
| References | |  |
| 1. | Verghese A, Brady E, Kapur CC, Horwitz RI. The bedside evaluation: Ritual and reason. Ann Intern Med 2011;155:550-3.  |
| 2. | Phoon CK. Must doctors still examine patients? Perspect Biol Med 2000;43:548-61. |
| 3. | Verghese A, Horwitz RI. In praise of the physical examination. BMJ 2009;339:b5448. [ PUBMED] |
| 4. | Nauwelaers J. Eraritjaritjaka. Lancet 2000;356:2169-70. |
| 5. | Nohria A, Stevenson LW. Observation is never obsolete. JACC Heart Fail 2014;2:32-4. |
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