Adeloye, Davies

Balogun, Olanrewaju

Oyedokun, Ayo

Croatian Medical Journal

PubMed

Ayo Oyedokun

Davies Adeloye

Olanrewaju Balogun

Crossref

Clinical history-taking and physical examination in medical practice in Africa: still relevant?

Covenant University Repository

605www.cmj.hrAyo Oyedokun1, Davies Adeloye2,3, Olanrewaju Balogun41Saint Nicholas Hospital, Lagos, Nigeria ayooyedokun@yahoo.com2Demography and Social Statistics, and the e-Health Research Cluster, Covenant University, Canaanland, Ota, Ogun State, Nigeria3Centre for Global Health Research and the World Health Organization’s Collaborating Centre for Population Health Research and Training, The University of Edinburgh Medical School, Usher Institute, Edinburgh, UK4Department of Surgery, Lagos University Teaching Hospital, Lagos, NigeriaClinical history-taking and physical examination in medical practice in Africa: still relevant?MEDICAL CHALLENGES IN AFRICA  Croat Med J. 2016;57:605-7 https://doi.org/10.3325/cmj.2016.57.605Advancement in technology is continually redefining the practice of medicine globally, with sophisticated diagnos-tic machines, investigative procedures, and medical tests now widely available for medical diagnosis. Indeed, new discoveries, devices, and the internet have positively in-fluenced the way physicians diagnose, treat, and palliate diseases. However, unlike in many high-income settings, where advancements in medical technology have, in most cases, been complementary to understanding disease pathogenesis and acquisition of core clinical skills, emerg-ing evidence from many low- and middle-income coun-tries, especially Africa, point to the contrary (1,2). There are widespread concerns about doctors’ declining bedside skills and clinical aptitude (3). While it is a requisite that medical students and doctors-in-training must demon-strate competence in history-taking and physical exami-nation, there are reports that doctors fail to maintain and improve on these skills over their professional practice ow-ing to over-reliance on results of medical tests (3). In Africa and many resource-constrained settings, where majority can hardly afford simple medical tests, the essence of de-tailed history-taking and physical examination cannot be overemphasized. It is therefore important to consider if im-provements in health technology and medical diagnosis, and their introduction in many African settings, should al-ter the role of the fundamental history-taking and physical examination in general clinical assessment.CliniCAl DiAgnOsis in meDiCAl prACtiCeA systematic approach to the bedside examination of a pa-tient is essential to determine the significance of an ab-normal physical finding. It aids critical thinking, actively searches for signs of disease, identifies possible diagnosis, and helps in making tentative management plans (1-4). Sackett and Rennie reported that a doctor’s first few min-utes of history-taking and physical examination are packed with audio-visual and tactile information about the patient, which may subsequently determine the path of diagnosis and effectiveness of treatment given (5).Clinical reasoning based on facts elicited from symptoms and signs in the history-taking and examination has to be tested against basic scientific background and knowl-edge acquired during medical training (6). Laboratory re-sults may therefore be seen as supporting evidence and not dictate over a meticulous clinical evaluation (6). In fact, the reliability of any laboratory information depends on the state of the medical equipment and the technologist’s ability to use it effectively (7). In some African settings, doc-tors order several tests to make diagnosis without consid-ering this fact and some other basic evidence from clinical research relevant to their environment (2). Results may be false positive or false negative, and in such cases, a lack of basic understanding of the disease present-MEDICAL CHALLENGES IN AFRICA 606 Croat Med J. 2016;57:605-7www.cmj.hring complaints may result in instituting a wrong treatment plan (7). In addition, this may result in incurring unneces-sary costs by the patient and overstretching the limited health resources in these settings. Moreover, ordering tests without detailed history-taking and physical examination tends to strain patient-doctor’s relationship (7). In the ab-sence of trust and confidence on the part of the patient, the effectiveness of most therapies fails. It is therefore im-portant that physicians remain purposeful in the care of patients and uphold strict professional conduct. A detailed interaction and observation during consultations can not be replaced by laboratory results.HistOrY-tAKing AnD pHYsiCAl eXAminAtiOn Vs inVestigAtiOnsIt has been widely reported that history-taking and physical examination in medical practice may have been declining across Africa due to poor consultation venues, overcrowd-ed clinics with few doctors to patients, poor salary packag-es for doctors, and the fact that to augment income, doc-tors often rely on bonuses and re-imbursements offered by manufacturers and pharmaceutical companies for using their diagnostic equipment and drugs (1,4). This practice has even led to a wrong perception among patients that laboratory tests and investigations must precede any diag-nosis and/or treatment. It is now not uncommon for pa-tients to walk into medical laboratories or radio-diagnostic centers to have investigations done even before consult-ing with a doctor. Invariably, the component of history-tak-ing and physical examination as contained in the holistic management of patient – consideration of the complete physical, psychological, social, and spiritual factors in the management and prevention of disease – is gradually fad-ing in the region (2,8). Studies have consistently shown that over-reliance on technology may not necessarily im-prove the quality of patient care (7). Hence, experts have ar-gued that the justification for any investigation in medical practice ought to be complementary – answering specific questions related to history-taking and physical examina-tion already done (1,4). For example, Reilly (4) reported that physical examination had substantial effects on the care of medical inpatients, with one-in-four patients ordered for investigation already having pivotal physical findings nec-essary for diagnosis. Some studies conducted in the Unit-ed States, India, and Brazil also reported that history-taking was responsible for 76%, 78.6%, and 77.8% of all diagno-ses made, respectively, and that investigations played complementary roles in excluding other diagnostic op-tions and increased physicians’ self-confidence (6-8). In fact, Dooley et al (9) explained that detailed clinical his-tory remained the mainstay of diagnosis for most of the critical cases of pediatric neurology they encountered in their practice. Additionally, a less equipped primary health care center may still arrive at a correct diagnosis in about 88% of cases following brief history-taking and physical ex-amination, and treatment can be commenced based on these findings (5).However, it is important to note that some patients do re-quire thorough investigations to arrive at a definitive diag-nosis and institute appropriate care (8). In a study among patients with developmental delay, Shevell et al (10) found medical investigations and imaging to be helpful in deter-mining etiologic diagnosis in about 30% of cases. Khunti et al (11) also emphasized that an objective investigation in-cluding laboratory tests, electrocardiogram, and echocar-diogram must be performed in patients with clinically suspected heart disease. Diacon (12) also noted that physi-cian’s clinical acumen may not predict the accuracy of se-lected puncture sites, but that a bedside ultrasonography potentially increases the yield and reduces complications during diagnostic pleurocentesis. It is also worthwhile to note that some investigations, asides from being diagnos-tic, may also be therapeutic, as is the case in endoscopies performed for some gastrointestinal, respiratory, or urinary tract diseases. Our view however is that while some inves-tigations may be necessary and very important in overall clinical management, this can still not replace a detailed medical history-taking and physical examination during consultations. Moreover, in many African settings, where patients can hardly afford costs of medical care, needless laboratory tests may be avoided to help reduce medical expenses. Positive management outcomes have been re-ported following scenarios where physicians used few investigations and tests owing to patient’s financial con-straints and lack of insurance schemes (12).COnClusiOnWe understand that our report may be incomplete due to the absence of original information, time variations, and precise quantitative data and analysis of the application of health technology, history-taking, and physical examina-tion across many African settings. Moreover, consideration of widespread differences in medical practice among var-ious African contexts may have further improved our re-port, as we still cannot characterize with all certainty the difference in the use of the health technology between Af-rica and other world regions. The lack of original research 607Oyedokun et al: Clinical history-taking and physical examination in medical practice in Africawww.cmj.hrappraising core clinical skills and health technology across many African countries is a major factor, and prospective studies are still constrained by lack of funds to conduct large population-representative studies from which evi-dence-based decisions may have emerged. As practicing physicians however, we support the opinion that technol-ogy may serve as an extension of a doctor’s core clinical duties and not be regarded as a replacement. We present this report to raise awareness on the relevance of history-taking and physical examination in the continent. We hope this will be re-emphasized in health policy and clinical cur-riculum guiding the training of medical students and resi-dent doctors, and overall medical practice across many Af-rican countries.references1 Bastos rr. physical examination. lancet. 2003;362:2022-3. medline:14683666 doi:10.1016/s0140-6736(03)15029-52 Adeloye D. Key challenges of evidence-based medicine in developing countries. research Journal of Health sciences. 2015;3:139.3 mcmahon gt, marina O, Kritek pA, Katz Jt. effect of a physical examination teaching program on the behavior of medical residents. J gen intern med. 2005;20:710-4. medline:16050879 doi:10.1111/j.1525-1497.2005.0159.x4 reilly Bm. physical examination in the care of medical inpatients: an observational study. lancet. 2003;362:1100-5. medline:14550696 doi:10.1016/s0140-6736(03)14464-95 sackett Dl, rennie D. the science of the art of the clinical examination. JAmA. 1992;267:2650-2. medline:1573756 doi:10.1001/jama.1992.034801900920406 Bensenor im. Do you believe in the power of clinical examination? the answer must be yes! sao paulo med J. 2003;121:223. medline:14989136 doi:10.1590/s1516-318020030006000017 roshan m, rao Ap. A study of relative contributions of the history, physical examination and investigations in making medical diagnosis. J Assoc physicians india. 2000;48:771-5. medline:112734678 peterson mC, Holbrook JH, Von Hales D, smith nl, staker lV. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J med. 1992;156:163-5. medline:15360659 Dooley Jm, gordon Ke, Wood ep, Camfield Cs, Camfield pr. the utility of the physical examination and investigations in the pediatric neurology consultation. pediatr neurol. 2003;28:96-9. medline:12699858 doi:10.1016/s0887-8994(02)00494-010 shevell mi, majnemer A, rosenbaum p, Abrahamowicz m. etiologic yield of subspecialists’ evaluation of young children with global developmental delay. J pediatr. 2000;136:593-8. medline:10802489 doi:10.1067/mpd.2000.10481711 Khunti K, Baker r, grimshaw g. Diagnosis of patients with chronic heart failure in primary care: usefulness of history, examination, and investigations. Br J gen pract. 2000;50:50-4. medline:1069507012 Diacon AH, Brutsche mH, sole’r m. Accuracy of pleural puncture sites: a prospective comparison of clinical examination with ultrasound. Chest. 2003;123:436-41. medline:12576363 doi:10.1378/chest.123.2.436

Clinical history-taking and

physical examination in

medical practice in Africa: still

relevant?

http://dx.doi.org/10.3325/cmj.2016.57.605

Clinical history-taking and physical examination in medical practice in Africa: still relevant?

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