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      I appreciate Volpintesta's response to our article on moving toward cost-effectiveness in physical examination,
      • Bergl P.
      • Farnan J.M.
      • Chan E.
      Moving toward cost-effectiveness in physical examination.
      and I wholeheartedly agree that throughput and efficiency often relegate physical examination to a mere ritual, particularly in inpatient settings. Indeed, diagnostic overuse likely has many causes, including patients' preferences for advanced testing, reimbursement models, and even fears of malpractice.
      The extent to which malpractice worries drive overuse is not entirely clear. Recent work has shown that defensive practices on hospitalist services might contribute very little overall to the cost of care.
      • Rothberg M.B.
      • Class J.
      • Bishop T.F.
      • et al.
      The cost of defensive medicine on 3 hospital medicine services.
      On the other hand, a contemporary survey of emergency physicians showed that fear of litigation is a perceived driver of overuse.
      • Kanzaria H.K.
      • Hoffman J.R.
      • Probst M.A.
      • et al.
      Emergency physician perceptions of medically unnecessary advanced diagnostic imaging.
      Nonetheless, state-level malpractice reform does not seem to correlate with reductions in defensive practices, at least in the emergency department.
      • Waxman D.A.
      • Greenberg M.D.
      • Ridgely M.S.
      • et al.
      The effect of malpractice reform on emergency department care.
      However, physical examination still could have a major role in reducing defensive medicine. First, by developing more robust evidence on physical examination's utility, physicians would have a stronger shield of diagnostic confidence and might order fewer imaging or laboratory studies. Also, if we systematically improve training in diagnostic reasoning and the principles of Bayesian probability, we would assuage our trainees' fears about missing important diagnoses. The next generation of physicians also would find objective tests less reassuring if regularly reminded that interobserver variability occurs in any diagnostic maneuver, whether it is a fluid wave for ascites or a breast biopsy specimen for detecting ductal carcinoma in situ.
      • Elmore J.G.
      • Longton G.M.
      • Carney P.A.
      • et al.
      Diagnostic concordance among pathologists interpreting breast biopsy specimens.
      Admittedly, physical examination may have a limited role in eliminating defensive practices and reducing costs of care. Instead, we should focus our educational efforts on areas that we can control in our training environments and practices. We need to promote cost-effective care through more parsimonious diagnostic evaluations and more accurate bedside diagnoses.

      References

        • Bergl P.
        • Farnan J.M.
        • Chan E.
        Moving toward cost-effectiveness in physical examination.
        Am J Med. 2015; 128: 109-110
        • Rothberg M.B.
        • Class J.
        • Bishop T.F.
        • et al.
        The cost of defensive medicine on 3 hospital medicine services.
        JAMA Intern Med. 2014; 174: 1867-1868
        • Kanzaria H.K.
        • Hoffman J.R.
        • Probst M.A.
        • et al.
        Emergency physician perceptions of medically unnecessary advanced diagnostic imaging.
        Acad Emerg Med. 2015; 22: 390-398
        • Waxman D.A.
        • Greenberg M.D.
        • Ridgely M.S.
        • et al.
        The effect of malpractice reform on emergency department care.
        N Engl J Med. 2014; 371: 1518-1525
        • Elmore J.G.
        • Longton G.M.
        • Carney P.A.
        • et al.
        Diagnostic concordance among pathologists interpreting breast biopsy specimens.
        JAMA. 2015; 313: 1122-1132

      Linked Article

      • Why the Physical Examination Gets No Respect
        The American Journal of MedicineVol. 128Issue 8
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          Seasoned clinicians recognize the importance of the physical examination, yet many physicians, as Bergl et al1 pointed out--particularly those who are still in training or are new to practice--seem to underestimate its value and place greater faith in imaging studies and blood tests.
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