Are you one of "The Trophy Generation"??

opinion guy

tallaght01 wrote: »

Just depends on what you're looking for from the examination, and how good the "operator" is.

Thats a variable.

Some disease have very specific findings, and others don't. You can't package them up into one homogenous "clinical" examination group.

Oh I agree with that. Some exams are better than others.

As far as I know Opinion guy studies/works in WIT and isn't a doctor, so don't get too stressed by what he says biologic.

Eh no idea where you are getting this stuff from. Never set foot in WIT in my life. And as before I'm not telling ye what I do. Frankly I enjoy watching you all jump to conclusions - its amuses me. Its fascinating to me how some doctors deal with opinions that are different to their own. But leaving that aside - take note dear readers, that I'm the one arguing the issues above. And tallaght01 if memory serves you are studying public health are you not? Then you are more than able of arguing on the merits of the argument and are very familiar with the techie terms I'm using above, are you not ??? Then why don't you ? Could it be you know I'm right and attacking the poster is all that you are left with ? i

Those of us who've been doing it, have seen consultants diagnose some crazy **** by just clinical examination, especially the old school consultants. We've also seen people who just scan/xray everyone who walks in the door.

Yeah. I've no doubt they do diagnose random ass stuff - but its not about that - its about whats missed. Do they diagnose the random ass stuff all the time ?

Biologic wrote:

No need to apologise for rudeness, I've thicker skin than that. I understand what the terms indicate. Presenting them as though there is absolutely no value in clinical examination made me think you didn't. It's a blatant false dichotomy to say that the only outcome relevant to clinical exam is the true neg/false pos rate. Examination gives essential input into forming a differential backed up with investigations. "Making it up" doesn't do this so the raw true + or - rates between chance and examination aren't comparable in isolation.

No I understand your point of view. Diagnosis is 90% history, 10% exam right. The point I am making however is that if you are basing the decision to do an investigation and your 90% history is inconclusive and you make your decision on the 10% clinical exam part you are highly likely to miss stuff. Especially if you are suffering under a delusionally high confidence in clinical examination.

More importantly, without clinical examination you wouldn't be able to arrive at your hypothetical situation whereby you have a diagnosis to get right or wrong. It's a null point to imply that you can just make up the specificity outcome (even if it is .5) because without examination you would have nowhere to go after that even if chance brought you the right answer. I'll admit I don't know enough to get into the intricacies of clinical examination, but to compare it to chance obviously isn't applicable. That's the point I want to make.

I'm sorry but you are just wrong here. Clinical history can often point the way to a diagnosis, but very often in disease states clinical examination findings may be absent. (And obviously I am not talking about ALL clinical examination but say taking the paper I linked above - placing any faith in 3rd and 4th heart sounds for example would be very foolhardy would it not ??).

Ihaveanopinion wrote:

Got to disagree with you again - opinion guy.

Err....we disagreed before, I must have missed that ????

There are numerous studies showing the high sensitivity and specificity of clinical examination. In fact, the common theme at the end of most of them is that expensive tests are often unnecessary. Clinical exam is more than waving a stethoscope at a chest.

A simple questionnaire to identify TIA (history taking I know - but a similar vein) Sens 82% Spec 62%

Not a clinical exam. History is very different to clinical exam. The old maxim - diagnosis is 90% history and 10% exam holds true. This finding does not surprise me.

Neuroepidemiology. 2011 Feb 10;36(2):100-104. [Epub ahead of print]
Sensitivity and Specificity of Stroke Symptom Questions to Detect Stroke or Transient Ischemic Attack. Sung VW, Johnson N, Granstaff US, Jones WJ, Meschia JF, Williams LS, Safford MM.

Again history

Testing a bunch of Subscap tests - Sens 80+%

Knee Surg Sports Traumatol Arthrosc. 2010 Dec;18(12):1712-7. Epub 2010 Apr 8. Diagnostic values of clinical tests for subscapularis lesions. Bartsch M, Greiner S, Haas NP, Scheibel M.

Sens 100% Spec 80 %

Physiotherapy. 2011 Mar;97(1):59-64. Epub 2010 Aug 1.
Reliability and diagnostic validity of the slump knee bend neurodynamic test for upper/mid lumbar nerve root compression: a pilot study.
Trainor K, Pinnington MA.

Sens 86% Spec 100%

Foot Ankle Int. 2011 Feb;32(2):189-92.
Validity of the posterior tibial edema sign in posterior tibial tendon dysfunction.
Deorio JK, Shapiro SA, McNeil RB, Stansel J.

you get the idea. Anyway, my point is - to state that clinical exam is essentially a coin toss is incorrect. A proper clinical exam can obviate the need for specialised testing.

Yeah I do get the idea (ok leaving aside the question of whether or not we are going to trust orthopods to do the stats that is :P). in fact I was waiting for someone to point out a good clinical test. For obviously above I was arguing the extremely negative point. Some clinical tests ARE useful in making a diagnosis. Few are useful in ruling out a diagnosis. But the point is we need to chuck out the **** ones don't we. Stop wasting students and teachers filling peoples head with the nonsense of 3rd and 4th heart sounds for example.

This is all a bit off point anyway. Someone who is in heart failure, of course, needs to be investigated appropriately.

Exactly. And listening for 3rd and 4th heart sounds is currently part of deciding whether or not they have heart failure for many docs. Should it be ? No. They should just get an echo.

Vorsprung

I think tallaght is mixing up imported guy and opinion guy

tallaght01

Vorsprung wrote: »

I think tallaght is mixing up imported guy and opinion guy

I dunno. someone on here told me he's a WIT person when we were talking about how much madness he writes.

It's obvious, however, that he's not medically trained, yet still goes on like he is. I know we don't all reveal our identities on here, but in fairness to virtually everyone else who posts here regularly, they will at least say what their specialty is, and usually their rank. You wouldn't trust it enough to give someone medical advice, but you get the feeling that it's the truth with most people. And it is relevant, IMO. I've met a few people from here, and they've always been what they said.

You can ban me for this, but opinion guy talks ****, and gently implies that he's qualified, and masks his reluctance to expand on his actual role as having something to do with liking people jumping to conclusions, which is of course crap. he's been doing it for a long time, and no end of people have commented on it. I don't care all that much, as I don't use this place that often. But it's worth pointing out.

A lot of people won't agree with that, and think that the option of total anonymity is essential. That's fair enough. It is in come cases. I doubt it is in this case.

I'll be gutted if he was mixed up with imported_guy, as I completely admire imported-guy's strategy of posting on the GAMSAT threads trying to put people off doing it, so there's less competition for him. It's an entrepreneurial spirit that we need in medicine :P

Vorsprung

People are entitled to anonymity if that's what they want. I got into a little bit of trouble when I said stated the speciality of a regular poster here - not bad trouble, he PMed me asking that I remove the reference but unfortunately I didn't see it for a few days, and a mod was asked to change it. My bad for assuming that people wanted their details made public.

You are of course entitled to your opinion, but so is everyone else, whether they work in a healthcare environment or not. As with disagreeing, that's fine, disagree but no need to air it repeatedly on the forum.

tallaght01

Vorsprung wrote: »

People are entitled to anonymity if that's what they want. I got into a little bit of trouble when I said stated the speciality of a regular poster here - not bad trouble, he PMed me asking that I remove the reference but unfortunately I didn't see it for a few days, and a mod was asked to change it. My bad for assuming that people wanted their details made public.

You are of course entitled to your opinion, but so is everyone else, whether they work in a healthcare environment or not. As with disagreeing, that's fine, disagree but no need to air it repeatedly on the forum.

People are absolutely entitled.

I just wonder about the reluctance. How much of a risk is it to say "I'm a cardiology SHO" or "I'm a biology student".

It's more the reluctance when asked that makes me suspect. But I see your point, and i'm not hugely bothered generally.

The poster who contacted you would be readily identifiable because of the other stuff he talks about, when combined with the info that you posted. Almost all of the medics here know him, and the fact that we know his background means we take what he says on certain non-clinical issues as being almost gospel.

Biologic

opinion guy wrote: »

Frankly I enjoy watching you all jump to conclusions - its amuses me. Its fascinating to me how some doctors deal with opinions that are different to their own.

opinion guy wrote: »

I'm sorry but you are just wrong here.

Fascinatingly hypocritical.

opinion guy wrote: »

Clinical history can often point the way to a diagnosis, but very often in disease states clinical examination findings may be absent. (And obviously I am not talking about ALL clinical examination but say taking the paper I linked above - placing any faith in 3rd and 4th heart sounds for example would be very foolhardy would it not ??).

So we've from "clinical exam is as good as chance" to "some clinical exam has reduced use". That's fine with me, point made.
Regarding my point that I'm apparently just wrong on. I'll be more succinct because it obviously didn't get through. Something is worth doing if it can change patient management. Clinical exam can, your idea of just making up the outcome can't. Therefore, they're not equal.

Vorsprung

Clinical exam is absolutely important!!

I saw a lady the other night who had some UTI symptoms. On exam she had a sore renal angle which she didn't realise she had, making her a pyelo. It was only mild, but it upgraded the diagnosis, purely on exam.

opinion guy

Biologic wrote: »

Fascinatingly hypocritical.


So we've from "clinical exam is as good as chance" to "some clinical exam has reduced use". That's fine with me, point made.
Regarding my point that I'm apparently just wrong on. I'll be more succinct because it obviously didn't get through. Something is worth doing if it can change patient management. Clinical exam can, your idea of just making up the outcome can't. Therefore, they're not equal.

Yup it sure can. Never said it couldn't. But NOT ALL THE TIME. The problem is people don't realise the limiitations. A positive exam is very useful. A negative exam is useless. If the history points to something then you will almost always have to do an investigation anyhow.

Vorsprung wrote: »

Clinical exam is absolutely important!!

I saw a lady the other night who had some UTI symptoms. On exam she had a sore renal angle which she didn't realise she had, making her a pyelo. It was only mild, but it upgraded the diagnosis, purely on exam.

Case in point. Positive exam being useful. But then I've also heard of relatively asymptomatic early pyelo being picked up on CT when it wasn't even in the differentials. As I keep saying - its not about what you catch with physical exam - its about what you miss!!!

opinion guy

tallaght01 wrote: »

I dunno. someone on here told me he's a WIT person when we were talking about how much madness he writes.

It's obvious, however, that he's not medically trained, yet still goes on like he is. I know we don't all reveal our identities on here, but in fairness to virtually everyone else who posts here regularly, they will at least say what their specialty is, and usually their rank. You wouldn't trust it enough to give someone medical advice, but you get the feeling that it's the truth with most people. And it is relevant, IMO. I've met a few people from here, and they've always been what they said.

You can ban me for this, but opinion guy talks ****, and gently implies that he's qualified, and masks his reluctance to expand on his actual role as having something to do with liking people jumping to conclusions, which is of course crap. he's been doing it for a long time, and no end of people have commented on it. I don't care all that much, as I don't use this place that often. But it's worth pointing out.

A lot of people won't agree with that, and think that the option of total anonymity is essential. That's fair enough. It is in come cases. I doubt it is in this case.

I'll be gutted if he was mixed up with imported_guy, as I completely admire imported-guy's strategy of posting on the GAMSAT threads trying to put people off doing it, so there's less competition for him. It's an entrepreneurial spirit that we need in medicine :P

Lol. Curious who you were discussing how much 'madness' I apparently write. Hmmm you see have your little rant here (no need to ban anyone mods). Tallaght01 I stick with the logical argument. You can't seem to help turning to ad hominems. If you disagree with my point of view then argue the point and give some data to back it up - I gave you data. And it doens't matter what my background is as long as my data and logic is valid - which it is.
Simply tallaght01 - do you believe that 3rd and 4th heart sounds are useful aspects of clinical examination ? And if you do please explain your veiwpoint in light of the study I linked to above.

ZYX

opinion guy wrote: »

Yup it sure can. Never said it couldn't. But NOT ALL THE TIME. The problem is people don't realise the limiitations. A positive exam is very useful. A negative exam is useless. If the history points to something then you will almost always have to do an investigation anyhow.

I don't see what you are trying to get at here. As a GP the vast majority of people I see and diagnose do not get an investigation to determine diagnosis. So in most cases you do not need an investigation.

Just some very common situations: Abdominal pain, history and examination (especially if exam is normal) are sufficient in most cases. Investigation of headaches- history and negative examination is enough. Skin rashes, viral infections/bacterial infections, mood disorders, the list goes on. In fact most things I see in general practice are best diagnosed with history and a negative examination.

opinion guy

ZYX wrote: »

I don't see what you are trying to get at here. As a GP the vast majority of people I see and diagnose do not get an investigation to determine diagnosis. So in most cases you do not need an investigation.

Just some very common situations: Abdominal pain, history and examination (especially if exam is normal) are sufficient in most cases. Investigation of headaches- history and negative examination is enough. Skin rashes, viral infections/bacterial infections, mood disorders, the list goes on. In fact most things I see in general practice are best diagnosed with history and a negative examination.

What I'm getting at is that depending on the examination the negative examination can be entirely misleading

ZYX

opinion guy wrote: »

What I'm getting at is that depending on the examination the negative examination can be entirely misleading

So when you said:
A positive exam is very useful. A negative exam is useless.
You didn't actually mean it:rolleyes:

The reality is, a negative examination is massively important in so many conditions and I would hazard that in GP it is more valuable in making a diagnosis than a positive exam.

opinion guy

opinion guy wrote: »

What I'm getting at is that depending on the examination the negative examination can be entirely misleading

ZYX wrote: »

So when you said:
A positive exam is very useful. A negative exam is useless.
You didn't actually mean it:rolleyes:

Eh what ? You just completely reversed the meaning of what I said.

Let me be clear:
A positive exam is very useful. A negative exam is useless = What I'm getting at is that depending on the examination the negative examination can be entirely misleading

These two statements are expressing the same sentiment.
Unless you have some alternate understanding of English that is.

Biologic

opinion guy wrote: »

Lol. Curious who you were discussing how much 'madness' I apparently write. Hmmm you see have your little rant here (no need to ban anyone mods). Tallaght01 I stick with the logical argument. You can't seem to help turning to ad hominems. If you disagree with my point of view then argue the point and give some data to back it up - I gave you data. And it doens't matter what my background is as long as my data and logic is valid - which it is.
Simply tallaght01 - do you believe that 3rd and 4th heart sounds are useful aspects of clinical examination ? And if you do please explain your veiwpoint in light of the study I linked to above.

For someone so versed on logical fallacies (accusing of ad Hominem attacks), you should know that what you're saying is a non-sequitur logical fallacy. Your data may be fine but your logic isn't. Maybe that study regarding heart sounds is right, it doesn't follow that clinical examination is bogus. That's what you implied initially and what riled people (me, anyway) up wrong. If you want to argue that some types of clinical examination have dubious benefits then go nuts, but your initial deductions were way off.

ZYX

You said:

opinion guy wrote: »

Yup it sure can. Never said it couldn't. But NOT ALL THE TIME. The problem is people don't realise the limiitations. A positive exam is very useful. A negative exam is useless. If the history points to something then you will almost always have to do an investigation anyhow.

That quite clearly says a negative exam is useless.
Now you are changing what you are saying to "a negative exam can be misleading". Well of course it can. But then a positive result can be even more misleading and a positive investigation can be even mote misleading again.

The reality is, a negative exam is a vital part if many diagnoses and results in no further investigations being needed

opinion guy

Biologic wrote: »

For someone so versed on logical fallacies (accusing of ad Hominem attacks), you should know that what you're saying is a non-sequitur logical fallacy. Your data may be fine but your logic isn't. Maybe that study regarding heart sounds is right, it doesn't follow that clinical examination is bogus. That's what you implied initially and what riled people (me, anyway) up wrong. If you want to argue that some types of clinical examination have dubious benefits then go nuts, but your initial deductions were way off.

I've said several times I don't mean all clinical exams. But many. I did word it that way initially but that was an error - I'll fixed that now. I am not saying that clinical exam is bogus and should not be done. I am saying that most people put way too much faith in it and that the more objective investigation based US approach is not such a bad thing.

ZYX wrote: »

You said:


That quite clearly says a negative exam is useless.
Now you are changing what you are saying to "a negative exam can be misleading". Well of course it can. But then a positive result can be even more misleading and a positive investigation can be even mote misleading again.

The reality is, a negative exam is a vital part if many diagnoses and results in no further investigations being needed

I'm sorry but this is just absolutely double speak. Misleading is WORSE than useless. Don't you get what I'm saying - making a decision based on a false negative physical examination finding is DANGEROUS AND YOU CAN MISS STUFF.

ZYX

opinion guy wrote: »

I
I'm sorry but this is just absolutely double speak. Misleading is WORSE than useless. Don't you get what I'm saying - making a decision based on a false negative physical examination finding is DANGEROUS AND YOU CAN MISS STUFF.

Congratulations. That must be the stupidest and illinformed comment ever on this forum. If you even lack the basics of how a diagnosis is made I cannot help you. Why do you assume a negative result is a false negative?

opinion guy

ZYX wrote: »

Congratulations. That must be the stupidest and illinformed comment ever on this forum. If you even lack the basics of how a diagnosis is made I cannot help you. Why do you assume a negative result is a false negative?

Why do you assume it isn't ?
My point is you don't know either way.

oh reported for personal abuse by the way.

ZYX

opinion guy wrote: »

Why do you assume it isn't ?
My point is you don't know either way.

oh reported for personal abuse by the way.

I abused the comment not the person.

Many diagnoses are dependent on a normal examination. Tension headaches & irritable bowel are just 2 common examples but there are many more. Now do you get it? Unless the exam is normal you cannot make the diagnosis. If the exam is abnormal then you may have to investigate. In that case the positive exam finding would have been misleading

PhysiologyRocks

History taking can be very productive. Examination can reveal a lot. Investigations can too. Emphasis on "can".

However, disease can be asymptomatic. Even if examination reveals lots of positive signs, the disease may or may not be present (same goes for negative signs). Tests can come back falsely positive or negative too.

No one system is infallible. All anyone can do is combine the above as sensibly as possible. All three aren't always necessary.

Asking how useful examination is is a bit like asking someone how fast their car is.

opinion guy

ZYX wrote: »

I abused the comment not the person.

Many diagnoses are dependent on a normal examination. Tension headaches & irritable bowel are just 2 common examples but there are many more. Now do you get it? Unless the exam is normal you cannot make the diagnosis. If the exam is abnormal then you may have to investigate. In that case the positive exam finding would have been misleading

Or you can find a falsely negative exam and misdiagnose them with tension headaches or IBS when actually something more sinister is going on.

How are you NOT getting this ?

ZYX

opinion guy wrote: »

Or you can find a falsely negative exam and misdiagnose them with tension headaches or IBS when actually something more sinister is going on.

How are you NOT getting this ?

One if us is NOT getting this and it is certainly not me.

MrCreosote

Things have gone off-topic a bit! But interesting none the less.

Personally I look at clinical exam as just another form of "test". Sometimes it does eliminate the need for further testing- applying the Ottawa ankle rules would be a good example. I'd suggest though that if you think about it it's always the history that is far and away most important. Take the IBS or tension headache examples- the differential diagnoses also are very likely to have no clinical signs, so really it's on history you're diagnosing it.

And yet the whole way it was taught to me in university was a bit of history and lots of time learning bullsh*t signs- I remember getting asked about fixed-splitting of the second heart sound once. FFS if someone can pick that they've obviously just read the Echo report.

opinion guy

ZYX wrote: »

One if us is NOT getting this and it is certainly not me.

Oh it most certainly is you. I find it scary that a GP cannot get their head around this (speaking as someone who has been misdiagnosed with IBS twice when actually I had something else going on - since treated successfully by someone who actually did the correct investigation despite normal abdo examination) .

The point is that physical examination is inaccurate. Some clinical exams more than others but all have some degree of inaccuracies. Therefore all diagnoses based on those clinical exams are subject ot inaccuracies - be the diagnoses based on positive exam findings, or diagnoses of exclusion like IBS. If you do not understand this basic concept then I fear for your patients.

Traumadoc

I think that the new acute medical and surgical units will make a difference , many patients who are seen by gps may have complaints that are probably benign but are potentially not.

A gp has the option of investigating themselves and try to access diagnostics but there are often very long and potentially dangerous waiting times.
Similarly the letter for Opd could result in a similarly long wait.

So what would you do ?

Take a chance and hope it is benign ?

I know if I were a gp I would refer to the fastest way to get a diagnosis -and refer to a&e. ( unless they were private and I know I would get appropriate and rapid diagnosis in st elsewhere :rolleyes:)

I know a lot of the emergency guys are delighted these new medical assessment units are opening.

Bella mamma

Our friend, Dr. Luke, is back in the news - Examiner and Evening Herald 15/2

Where does he find the time seeing 30+ patients a day?

http://www.herald.ie/national-news/gps-who-get-paid-then-refer-patients-to-casualty-2540627.html

http://www.examiner.ie/ireland/health/claim-aes-suffer-from-lazy-gp-referrals-145277.html

RobFowl

Bella mamma wrote: »

Our friend, Dr. Luke, is back in the news - Examiner and Evening Herald 15/2

Where does he find the time seeing 30+ patients a day?

http://www.herald.ie/national-news/gps-who-get-paid-then-refer-patients-to-casualty-2540627.html

http://www.examiner.ie/ireland/health/claim-aes-suffer-from-lazy-gp-referrals-145277.html

I really hate to say it but am very tempted to report him to the medical council for this sort of nonsense........

Big_G

The problem with relying on history alone in making a diagnosis is that you are relying on what the patient tells you. Patients are often stupid, and sometimes liars. Objective examinations don't have this problem.

Give me a bright light and a pokey anyday. I do listen to what the patient tells me and I know what is wrong with them most of the time before I even look, but still, history without exam would be useless, just as exam without history wouldn't be very useful, or would take an inordinate amount of time.

resus

RobFowl wrote: »

I really hate to say it but am very tempted to report him to the medical council for this sort of nonsense........

What, for telling the truth? Polarised it may be, but there is a whole lot of truth to what he writes. Yes it makes me fume, but the more I read YOUR replies, the more I side with his admittedly far right views.

I write unambiguously again, the Mercy ED, his department, is currently the ONLY ED I know of where NCHDs full contractual rights are being upheld! ie. they get ALL their holidays, study leave, etc. and don't work over the legal limit of an ave. 48hr week, etc. Also ALL his SHOs get off for teaching sessions, ALL, every time ! Let he be without sin cast the 1st stone.

ZYX

resus wrote: »

What, for telling the truth? Polarised it may be, but there is a whole lot of truth to what he writes. Yes it makes me fume, but the more I read YOUR replies, the more I side with his admittedly far right views.

I write unambiguously again, the Mercy ED, his department, is currently the ONLY ED I know of where NCHDs full contractual rights are being upheld! ie. they get ALL their holidays, study leave, etc. and don't work over the legal limit of an ave. 48hr week, etc. Also ALL his SHOs get off for teaching sessions, ALL, every time ! Let he be without sin cast the 1st stone.

The question is, what has Dr Luke done about it. Has he reported the GPs in question to the Medical Council or at the very least to the HSE? He is making serious allegations that if true should be investigated and the GPs involved reprimanded in some way and at the very least offered retraining.

Has he been in discussions with local GPs (not simply dictate his views to them) about how to improve things in the emergency dept? Has he a system in place where patients seen in A&E get reviewed by their own GP? Has he discussed local needs? Has he joined forces with local GPs in trying to improve services for patients or has he just decided he is right and people who don't agree with him are wrong?
He strikes me as the type of doctor who loves the sound of their own voice. Unless he has addressed these issues elsewhere and cannot get the issue resolved then I don't see why he is writing about it in newspapers.