Readers’ Comments
Figure 1.
Figure 2.
Firas Albadarin, MD David S.H. Bell, MD James H. O’Keefe, MD Kansas City, Missouri 17 November 2014
1. Buisson M, Cornu C, Nony P. Erroneous event count in a meta-analysis (DPP 4 inhibitors in type 2 diabetes mellitus). Am J Cardiol 2015;115:852. 2. Patil HR, Al Badarin FJ, Al Shami HA, Bhatti SK, Lavie CJ, Bell DS, O’Keefe JH. Metaanalysis of effect of dipeptidyl peptidase-4 inhibitors on cardiovascular risk in type 2 diabetes mellitus. Am J Cardiol 2012;110: 826e833. 3. Chan JC, Scott R, Arjona Ferreira JC, Sheng D, Gonzalez E, Davies MJ, Stein PP, Kaufman KD, Amatruda JM, Williams-Herman D. Safety and efficacy of sitagliptin in patients with type 2 diabetes and chronic renal insufficiency. Diabetes Obes Metab 2008;10:545e555. 4. Scirica BM, Bhatt DL, Braunwald E, Steg PG, Davidson J, Hirshberg B, Ohman P, Frederich R, Wiviott SD, Hoffman EB, Cavender MA,
Udell JA, Desai NR, Mosenzon O, McGuire DK, Ray KK, Leiter LA, Raz I. Saxagliptin and cardiovascular outcomes in patients with type 2 diabetes mellitus. N Engl J Med 2013;369: 1317e1326. 5. White WB, Cannon CP, Heller SR, Nissen SE, Bergenstal RM, Bakris GL, Perez AT, Fleck PR, Mehta CR, Kupfer S, Wilson C, Cushman WC, Zannad F. Alogliptin after acute coronary syndrome in patients with type 2 diabetes. N Engl J Med 2013;369:1327e1335. http://dx.doi.org/10.1016/j.amjcard.2014.11.017
Bedside Physical Examination Is Not Obsolete I read the study by Silverman and Gertz.1 Contrary to what is implied by the authors in their discussion, I am a vocal proponent of the clinical examination— as my patients, colleagues, and trainees will attest. Indeed, I was wounded by
853
their implication that I do not believe cardiac physical examination plays an essential role in patient care. If the authors had more thoroughly discussed my article,2 they would have recognized the comments they cited represented a “protagonist” view; my conclusions however were that the “antagonist” view—that is, the physical examination will continue to be an important and central part of patient care—will continue to rule for the foreseeable future. Moreover, although I agree there is a paucity of studies on the accuracy of bedside examination, I have contributed to the literature on honing the cardiac physical examination,3e5 a fact the authors have overlooked. Their article points to a widespread problem that in my opinion and that of many others will only serve to increase health care costs due to a “dumbing down” of clinical assessment and clinical thinking. Particularly disturbing is their finding that some 75% of surveyed midlevel providers do not even recognize basic heart sounds! Poor clinical assessment will not only lead to more testing, but poor clinical judgment will stem from an inability to place the results of such testing in the context of overall patient health. I applaud the authors on their survey and hope this will further heighten attention to this important public health issue. Colin K.L. Phoon, MPhil, MD New York, New York 7 December 2014
1. Silverman B, Gertz A. Present role of the precordial examination in patient care. Am J Cardiol 2015;115:253e255. 2. Phoon CK. Must doctors still examine patients? Perspect Biol Med 2000;43:548e561. 3. Phoon CK. Estimation of pressure gradients by auscultation: an innovative and accurate physical examination technique. Am Heart J 2001;141: 500e506. 4. Phoon CKL. A Guide to Pediatric Cardiovascular Examination or, How to Survive an Outreach Clinic. Philadelphia, PA: Lippincott-Raven; 1998. 5. Phoon CKL. Continual practice with echocardiography improves clinical estimation of pressure gradients [abstract, presented at the American Society of Echocardiography Annual Scientific Sessions, June 13, 2011, Montreal, Quebec, Canada]. J Am Soc Echocardiogr 2011;24:B49. http://dx.doi.org/10.1016/j.amjcard.2014.12.028
Figure 1.
Figure 2.
Firas Albadarin, MD David S.H. Bell, MD James H. O’Keefe, MD Kansas City, Missouri 17 November 2014
1. Buisson M, Cornu C, Nony P. Erroneous event count in a meta-analysis (DPP 4 inhibitors in type 2 diabetes mellitus). Am J Cardiol 2015;115:852. 2. Patil HR, Al Badarin FJ, Al Shami HA, Bhatti SK, Lavie CJ, Bell DS, O’Keefe JH. Metaanalysis of effect of dipeptidyl peptidase-4 inhibitors on cardiovascular risk in type 2 diabetes mellitus. Am J Cardiol 2012;110: 826e833. 3. Chan JC, Scott R, Arjona Ferreira JC, Sheng D, Gonzalez E, Davies MJ, Stein PP, Kaufman KD, Amatruda JM, Williams-Herman D. Safety and efficacy of sitagliptin in patients with type 2 diabetes and chronic renal insufficiency. Diabetes Obes Metab 2008;10:545e555. 4. Scirica BM, Bhatt DL, Braunwald E, Steg PG, Davidson J, Hirshberg B, Ohman P, Frederich R, Wiviott SD, Hoffman EB, Cavender MA,
Udell JA, Desai NR, Mosenzon O, McGuire DK, Ray KK, Leiter LA, Raz I. Saxagliptin and cardiovascular outcomes in patients with type 2 diabetes mellitus. N Engl J Med 2013;369: 1317e1326. 5. White WB, Cannon CP, Heller SR, Nissen SE, Bergenstal RM, Bakris GL, Perez AT, Fleck PR, Mehta CR, Kupfer S, Wilson C, Cushman WC, Zannad F. Alogliptin after acute coronary syndrome in patients with type 2 diabetes. N Engl J Med 2013;369:1327e1335. http://dx.doi.org/10.1016/j.amjcard.2014.11.017
Bedside Physical Examination Is Not Obsolete I read the study by Silverman and Gertz.1 Contrary to what is implied by the authors in their discussion, I am a vocal proponent of the clinical examination— as my patients, colleagues, and trainees will attest. Indeed, I was wounded by
853
their implication that I do not believe cardiac physical examination plays an essential role in patient care. If the authors had more thoroughly discussed my article,2 they would have recognized the comments they cited represented a “protagonist” view; my conclusions however were that the “antagonist” view—that is, the physical examination will continue to be an important and central part of patient care—will continue to rule for the foreseeable future. Moreover, although I agree there is a paucity of studies on the accuracy of bedside examination, I have contributed to the literature on honing the cardiac physical examination,3e5 a fact the authors have overlooked. Their article points to a widespread problem that in my opinion and that of many others will only serve to increase health care costs due to a “dumbing down” of clinical assessment and clinical thinking. Particularly disturbing is their finding that some 75% of surveyed midlevel providers do not even recognize basic heart sounds! Poor clinical assessment will not only lead to more testing, but poor clinical judgment will stem from an inability to place the results of such testing in the context of overall patient health. I applaud the authors on their survey and hope this will further heighten attention to this important public health issue. Colin K.L. Phoon, MPhil, MD New York, New York 7 December 2014
1. Silverman B, Gertz A. Present role of the precordial examination in patient care. Am J Cardiol 2015;115:253e255. 2. Phoon CK. Must doctors still examine patients? Perspect Biol Med 2000;43:548e561. 3. Phoon CK. Estimation of pressure gradients by auscultation: an innovative and accurate physical examination technique. Am Heart J 2001;141: 500e506. 4. Phoon CKL. A Guide to Pediatric Cardiovascular Examination or, How to Survive an Outreach Clinic. Philadelphia, PA: Lippincott-Raven; 1998. 5. Phoon CKL. Continual practice with echocardiography improves clinical estimation of pressure gradients [abstract, presented at the American Society of Echocardiography Annual Scientific Sessions, June 13, 2011, Montreal, Quebec, Canada]. J Am Soc Echocardiogr 2011;24:B49. http://dx.doi.org/10.1016/j.amjcard.2014.12.028
