Changes in Barriers to Primary Care and Emergency Department Utilization

agnosis was evaluated, not the management of the patient. Today, in the patients being evaluated for possible cardiovascular disease, echocardiography would be more often used in arriving at a diagnosis and especially in making management decisions for the patient. The modern imaging techniques when used appropriately have made the diagnosis of the patient’s disease and management more timely and accurate. There is also no doubt that these imaging techniques are overused, both to reassure the physician that a proper diagnosis was made and to act as a defensive measure against a claim of malpractice. Although these imaging tests are generally benign as far as adverse events are concerned, for certain, these techniques increase the cost of medical care significantly. In an era when the medical dollar must be spent wisely since we have reached the bottom of the money barrel for medical care, we physicians must be responsible for using these studies only when they add significantly to the diagnosis or aid in an important way to management decisions. When I first read the article by Paley et al, I mentally recognized that “I knew it all along.” As a teacher of medical students, house staff, and cardiology fellows I have become increasingly aware that there has been ever decreasing time spent teaching the basic skills of history taking and physical examination, especially cardiac auscultation. As a cardiologist, I see less attention paid to these basic skills and especially to auscultation, considered by many no loss since echocardiography has been developed. It is impossible to argue against a technique that is more accurate than auscultation in diagnosing cardiac diseases and helpful in designing an approach to treatment. However, in an era when amazing imaging can determine a diagnosis and practice guidelines for management of most diseases are available, the physician, as opposed to the technician, adds only 2 things that are indispensable in caring for patients: the physicianpatient relationship and informed judgments in making therapeutic decisions. The physician-patient relationship is formed at the time of initial contact during the taking of an attentive history and the performance of a careful physical examination. When the time comes to deciding that the patient needs surgery or an expensive or uncomfortable diagnostic study, without the confidence that the physician is knowledgeable and completely involved in their problem, it is likely that the patient will seek other opinions until they find someone they trust. The study by Paley et al is highly supportive of the physician’s ability using the classic diagnostic tools including a medical history, the physical examination, and basic laboratory studies to make an accurate diagnosis, reserving the expensive imaging techniques for those patients for whom there is diagnostic confusion or when difficult management decisions must be made. In this way, we can help reduce the cost to the patient without compromising the quality of their care.