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Re: Reply to Potts and Smith

We thank Drs. Potts and Smith for their interest in our article. The idea of improved efficiency in the ED with respect to history and physical exam is precisely the one we have explored with this study and with an upcoming study “Focusing on a serious review of systems” that will appear in next month’s issue of The Journal of Emergency Medicine. Like the general core physical exam, it is rare, in my experience, for the review of systems to reveal anything that changes acute patient management. So, why do we continue these ineffective portions of patient evaluation? And why is it necessary to document ten review of systems questions for a higher level of billing? It is our belief that too much of medical practice is carried on without proof of any benefit for patients, further encumbering our strained emergency health care system.

Their point about possible legal action when performing extensive examinations without consent is not an issue that we had thought of. Given the legal climate in the United States, it could be an even greater potential problem here.

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Re: Focussed or extended examination?

Dear Sir, We read with interest the article by Rodriguez and Phelps (1), which suggests that patients in the Emergency setting may be ‘over-examined’ for a variety of reasons including concerns regarding litigation, opportunistic health screening and habits learnt during medical training. In our department we try to emphasise the value of focussed history taking and physical examination, as supported by Curriculum of the College of Emergency Medicine (2) “to treat patients effectively and efficiently by prioritising tasks using a focussed history and examination…”. This is especially true in the light of increased efficiency requirements in the modern NHS. We too have found that some clinicians continue to perform extended core examinations, and in general this is stated to be as a result of previous training and experience. While, on occasions, there are good clinical reasons to perform an extended examination in patients with isolated limb injuries, clinicians need to be aware that they may be putting themselves at risk of compliant or litigation. The General Medical Council guidance on Good Medical Practice states that “You must be satisfied that you have consent…before you undertake any examination…Usually this will involve providing information to patients in a way they can understand before asking for their consent.”.(3) If this consent is not correctly sought, and the need for the extended examination clearly documented in the clinical records, then clinician’s actions could be open to mis-interpretation. We have involved with a number of cases of alleged indecent assault involving clinicians which have arisen in such circumstances. Consideration should always be given to the use of appropriate chaperones (4), otherwise the clinicians may find themselves undergoing a focussed examination in a court of law!

Yours faithfully

David J Potts, Simon M Smith Consultants in A&E