One of Houston's major hospitals decided recently to check up on its residents and interns, the doctors who perform most of the patient care in an increasing number of hospitals.
It found that these young men and women either missed at least one important symptom or made a significant error in interpreting a symptom in nearly two-thirds of their patients.
This situation is common in American medical care, said Dr. Nelda Wray, one of the physicians who made the study at the 1,100-bed Houston Veterans Administration Hospital, which is affiliated with the Baylor University College of Medicine.
The tendency isn't confined to the residents and interns who make up house staffs, she added. Other studies have shown that older, more experienced doctors, even the senior staff at a Harvard teaching hospital, often do no better and sometimes do worse.
It is the result, she said, of a growing tendency to slight the traditional physical examination and careful history and "let machines make our diagnoses."
The solution, said Wray and Dr. Joan Friedland in an article in today's Journal of the American Medical Association, is threefold: more time at the bedside, more attention to patients' complaints and condition, and more supervision of the doctor who makes the initial examination and diagnosis.
Wray and Friedland started their study by having eight senior staff doctors repeat the physical examinations made by 12 typical "house officers"--interns and residents--of 209 patients. The senior doctors found a total of 185 important symptoms missed by the house officers, and another 71 findings that they had to correct.
"We're not talking about missing an ingrown toenail," Wray said. "We're talking about missing important findings, an enlarged liver or spleen or a cardiac murmur or a skin rash that could be a sign of cancer. We're talking about findings that would significantly change and improve the treatment."
With some patients, the house officers missed several findings. The interns made some error, either missing something or misinterpreting something, in 56 to 73 percent of their patients; the residents, in 31 to 79 percent.
Interns are medical school graduates in their first year of hospital training; residents are in their second or third years or beyond.