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Diagnostic and Prognostic Testing in Pneumonia
- Joshua P. Metlay, MD, PhD; and
- Michael J. Fine, MD, MSc
- From Center for Health Equity Research and Promotion, Veterans Affairs Medical Center, Philadelphia, PA 19104; and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA 15240.
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IN RESPONSE:
We agree that a key explanation for the observed poor accuracy of the physical examination in the diagnosis of community-acquired pneumonia is the documented level of poor interobserver agreement among clinicians. We also agree that studies have suggested that the level of agreement among clinicians does not improve as a function of years of training. What remains unclear, however, is whether more expanded effort to train undergraduate and graduate medical students in the skills of bedside examination will yield improved performance characteristics for these diagnostic tests. There is little reason to undertake educational efforts designed to improve the reliability of physical examination skills that may never have sufficient sensitivity and specificity to appropriately alter management strategies. We acknowledge that papers such as ours that highlight the deficiencies of the physical examination may create self-fulfilling prophecies, whereby less emphasis on physical examination skills will lead to poorer skill performance and lower levels of diagnostic accuracy at the bedside. Regardless, until well-designed studies demonstrate that a better bedside physical examination can lead to better care, we cannot recommend a detailed physical examination for the management of patients with community-acquired pneumonia.
Joshua P. Metlay, MD, PhD
Center for Health Equity Research and Promotion; Veterans Affairs Medical Center; Philadelphia, PA 19104
Michael J. Fine, MD, MSc
Center for Health Equity Research and Promotion; VA Pittsburgh Healthcare System; Pittsburgh, PA 15240
- Copyright ©2004 by the American College of Physicians
