Veterinary Medicine - October 2008 - (Page 535)

veterinary schools, the fear of uncertainty, the availability of sophisticated diagnostic tests, and even ﬁnancial factors also play roles in the demise of the physical exam. Veterinary school de-emphasis In talking with new graduates over the years, I’ve concluded that many veterinary schools are not emphasizing the physical exam. I remember taking a physical diagnosis class as a sophomore in veterinary school. A general practitioner taught the course, and she had mixed feelings regarding the value of the skills she was teaching. The course was a pass-or-no-pass, one-unit class sandwiched between rigorous physiology and anatomy courses. It was a fun but devalued class, and we students viewed it as a rest stop, a break from the rigors of the important subjects. In that class, we did learn about the importance of a wellness exam, but we spent little time on abnormal ﬁndings because those were to be covered in clinics. Unfortunately, I encountered similar attitudes toward physical diagnosis in clinics. Many of the interns and residents focused on teaching the value of running diagnostic tests instead of conducting good physical exams. Who had time to perform a complete physical exam? We all had to check on 12 patients and participate in rounds. As today’s clinical faculty faces increasing time constraints, it’s likely that even less time is being spent on teaching physical diagnostic skills. Another reason educators may not be emphasizing these skills is because they lack conﬁdence in their skills. Some teachers’ greatest vulnerabilities may be in the clinics. bral disk with only 99% probability, then there is an almost irresistible urge to perform an MRI to close the gap. This is the fear of uncertainty. Further compounding this fear is pressure from the legal profession. Although a poor reason to order diagnostic tests, the litigious nature of our society often demands it. Since so much more is now known and knowable in veterinary medicine than in the past, our profession is viewed as an absolute science. As a result, more of us are shying away from making educated guesses based on the physical exam ﬁndings and are practicing defensive medicine for fear of being sued. Turning to technology Some believe that it is good science to use our new technology earlier and more prevalently—the technology as a toy argument.2 By playing with the toy, we can learn to use it better and, perhaps, discover the unexpected. Moreover, there are greater ﬁnancial rewards for ordering tests than for picking up on subtle physical exam ﬁndings. Technology can produce good science—the discoveries by Galileo through his telescope, for example.2 But technology can mislead, such as when an incidental ﬁnding on a radiograph or an artifactually elevated laboratory value on a screening blood Duke’s elusive diagnosis: An illustration of the importance of history taking You don’t need to ask owners every historical question possible, but you should take the time to ask the important ones. In my experience, the answers can greatly help you in diagnosing a disease and prescribing an appropriate treatment. Several years ago, Duke, a 4-year-old neutered male Brittany spaniel, was presented to me for evaluation of a waxing and waning fever and malaise of about six months’ duration. Duke had been seen previously by ﬁve veterinarians and had already undergone a battery of diagnostic tests including echocardiography, computed tomography, and abdominal ultrasonography. Unfortunately, all of the test results were inconclusive. After introducing myself to the client, I obtained a good history. It wasn’t until I asked the owner about his hobbies and travel history that a differential diagnosis started to become apparent. The client, who was an avid hunter, spent most of his vacations in the Southwest, hunting and ﬁshing with his dog. On physical exam, Duke’s gait showed a slight weight-bearing lameness affecting his right forelimb. Palpation of the right forelimb revealed mild discomfort. Duke also had mild bilateral keratitis. Although there were many possible causes of Duke’s clinical signs, based mainly on the dog’s history, I thought coccidioidomycosis was the most likely culprit. Laboratory tests conﬁrmed the diagnosis. The client was thankful for ﬁnally having a diagnosis, and Duke recovered completely after appropriate therapy. There is no question that imaging and laboratory tests play a key role in determining a difﬁcult diagnosis. But it’s the physical exam and history taking that account for most diagnoses. Fear of uncertainty If a physical exam permits a veterinarian to diagnose a herniated interverte- VETERINARY MEDICINE October 2008 535

Table of Contents Feed for the Digital Edition of Veterinary Medicine - October 2008

Veterinary Medicine - October 2008 Contents Leading Off Clinical Exposures Idea Exchange Stalking Stones Vaginitis in Dogs CE Form Advertiser Index Marketplace/Classifieds Mind Over Miller

Veterinary Medicine - October 2008

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