Yesterday in class my students learned, incidentally, just a bit about the vital signs that doctors sometimes measure as part of the physical exam. It turns out this is the subject of a recent med-blog debate:
The discussion started on db’s Medrants, with a Sept 9 admonition that if orthostatic vital sign measurements are needed to evaluate someone – presumably in a hospital setting — the intern and resident doctors should take those measurements themselves rather than writing an order for someone else, such as a nurse, to do it instead.
The problematically anonymous Happy Hospitalist commented there, calling the task a “nursing function.” He posted his views on Sept 10 and took the trouble to provide his readers a fairly detailed explanation of what it means to take those sometimes crucial measurements of a patient’s pulse and blood pressure when they’re lying down, sitting and standing.
After some additional back-and-forth, on Sept. 13 the somewhat anonymous author of Musings of a Dinosaur summarized the matter:
There are two different issues being discussed that are being incorrectly conflated:
- The value of orthostatic vital sign measuresments, and
- Who should be doing them, nurses or doctors.
Her position, as I understand it, is that there’s no fundamental reason why an assistant can’t perform this kind of work but, as a practical matter there’s somtimes no one else to do it but the physician, who shouldn’t feel it’s beneath her to measure a patient’s vital signs.
My interest, as far as medical education goes, is this: I think it’s really important that doctors be trained in how to perform a complete physical exam including the basic vital signs – pulse, respiratory rate, blood pressure and temperature (for the latter 2, with a device that works!). Here are two reasons why this matters:
1. I’ve witnessed cardiac arrests and near-arrests when it wasn’t so easy for the doctors and nurses to discern if the patient had a pulse or a viable blood pressure. Doctors need to know what they’re doing, and practice makes it more likely they’ll know if there’s a pulse and what is the patient’s pressure during stressful, rushed situations like a code.
2. Subtle abnormalities in a patient’s respiratory rate and pulse can be signs of serious illnesses. If a doctor’s unaccustomed to measuring those while talking with the patient and critically thinking, he or she may not pick up on those “easy” clues about what’s wrong, i.e. the diagnosis.
(As far as taking orthostatic measurements, a more time-consuming and less-frequently needed procedure, I think doctors should learn how to measure those and have some experience in doing so, in part so they’ll be familiar with the method and its potential limitations.)
But — I don’t see how we can afford, routinely, for senior, seasoned physicians (such as hospitalists in hospitals and doctors in other large, bulk-care settings) spending their time taking patients’ blood pressure and other vital signs. As a society, we just don’t have sufficient health care resources to indulge this kind of medical practice.
I want my doctors to spend more of their time reading and thinking about their patients, besides sleeping and taking care of themselves.
So while this little debate might seem minor and technical, reflecting some pettiness and distinct personalities among the various physician-bloggers, it bears on a serious issue for medicine, which is not so easily resolved: what are the tasks that we really want doctors to do, and not to delegate.
This discussion relates to a recent editorial in the New York Times on whether we really need physicians to administer anesthesia. (For the record, I think the answer is “yes.”) It bears also on simpler matters — whether doctors should spend time calling patients themselves about routine test results, adjusting coumadin and other drug doses or performing other tasks. What will be critical is how well we train technicians, aides, nurses and others who we’ll need, and increasingly rely on, whether we like it or not, to assist physicians in the future.
Well said! As you point out, the problem with delegating certain skills is that they are inevitably lost by those who delegate them, because eventually they are no longer able to perform them personally. Dr. Centor was discussing a training setting, where one would think it would be considered important to develop various skills in the first place. His lament was that his trainees were already delegating tasks they didn’t think they’d need in the future.
I agree that the issue of what doctors, as opposed to nurses and other technicians, should be doing is a valuable one that should be discussed explicitly.
Thanks for addressing this.
Let me extrapolate from your post by asking you how well do feel that today’s physicians, particularly the younger ones, perform at physicial diagnosisis. Can you compare their auscultatory skills and palpation of the abdomen to their predecessors? Are their skills (and ours) what they should be?
Hi Michael,
I’m afraid these skills are fading; there are few U.S.-trained instructors to teach methods of auscultation and palpation to students now. It may be, for this reason among others, that having more doctors who’ve been trained abroad — where doctors rely less on sonos, CTs and the like — will be helpful.