Comments From a Dental Colleague
As the Dental Health Director of a nonprofit health clinic in lower northwest Michigan that serves adults from three counties who are at or below the poverty level, I appreciated the information in your article “Taking a Bite Out of Disparities” (Clinician Reviews. 2010;20[11]:cover, 29, 30, 34, 42). We have challenges daily regarding our patient’s total health relating to their oral health.
Many of our adults have not had many dental office visits—some of them only for pain or extractions. We have a program that includes a session on basic brushing and flossing and education on the cause of infection in the mouth.
A grant allowed us to purchase an intraoral camera, which has been very educational for patients. Until May 2010, we were working with a three-year Health Resources and Services Administration grant that allowed us to conduct a school program as well.
All of the disease we found was preventable, and we are working on helping to change access to dental care for children as much as our current funds allow. It would be great to have a dental hygienist to visit schools and help families navigate to that care and to conduct prevention classes as well.
I think we all have the responsibility to share the treatment of the total person, and collaboration, as you state, is a vital key in that treatment.
Rene Louchart, RDH, BS, Traverse City, MI
The “Lost Art” of Physical Examination Lives
I just read the editorial by Randy D. Danielsen, PhD, PA-C, DFAAPA, in the November issue (Preserving a “lost art.” Clinician Reviews. 2010;20[11]:cover, 14-16). I totally agree that hands-on physical examination is a dying art.
When I taught nursing and nurse practitioner students, physical exam was one of my subjects. One reason I delighted in teaching that topic was my memory of finding things on physicals that had gone previously undetected.
When I was a student NP, my preceptor and I called on a patient from the local VA hospital. I was left to examine him. Having been intrigued by the possibility of finding things in the thorax just by having the client say “99” and by percussing the posterior thorax, I pulled out all the stops just to get some practice in on a “real patient” instead of one of my classmates. As a result of being thorough—really more for my sake than his—I found a tumor in his right lung.
A similar thing happened when I had my NP students perform physical exams on people they had invited to be their “patient” for the exam day. I was sitting facing the man who was the “patient” and was able to see my student’s face as she was palpating, percussing, and auscultating his thorax. After she had him perform pectoriloquy, the look on her face said either she had messed up or there was something she was hearing that she didn’t quite understand. I offered to repeat the exam and she was right: Something was wrong with this otherwise healthy man (her boyfriend). He went to his primary care provider and was found to have a tumor in his left lung.
I think both of these examples (and there are many more) refute Dr. Danielle Ofri’s statement in the New York Times that “There is scant evidence to suggest that routinely listening to every healthy person’s lungs, or pressing on every normal person’s liver, will find a disease that wasn’t suggested by the patient’s history.”
I recently “interviewed” a new-to-me MD to be my primary care provider. One of the things that sold me was her attention to detail and her excellence at physical examination.
Thanks for the article. It’s comforting to know that I’m not the only one with a passion for this topic.
Liz Wheeler, RN, DNS, WHNP, Staten Island, NY
I am a pediatric nurse practitioner who works in a genetics and metabolism program. Most of the children I see require thorough H&P to get at the underlying problem. Many times, it is the history (and physical) that helps us narrow down a differential rather than flying blind and ordering an unnecessarily large number of tests. Therefore, my expectation is high that other providers will take advantage of the answers that can be gleaned from a comprehensive H&P. Unfortunately, experience has shown me otherwise.
In efforts to try and consolidate my care into one institution, I was thinking of switching cardiologists. In doing so, I saw one for a consultation in anticipation of this transition. As a new consult, I was appalled that all he did was listen to my heart—there was no checking pulses, no checking for jugular venous distention, no observation for edema, and the list continues. Of course, he did order an expensive echocardiogram to evaluate how things looked.