La decaida de la exploracion fisica

PE R S PE C T IV E

Facing the Diabetes Epidemic

amended in December 2005, states that glycosylated hemoglobin test results and other identifying information “shall be confidential and shall not be disclosed to any person other than the individual who is the subject of the report or to such person’s treating medical providers,” with the exception that information about a minor may bedisclosed to a parent or legal guardian. Thus, the information should be unavailable for other purposes, such as to make it more difficult for a person with diabetes to obtain or renew a driver’s license, health insurance, or life insurance. However, concern about privacy and confidentiality will remain, at least until the registry is fully operational and the health department is able to demonstratethat there have been no substantial breaches. A disease registry is not a substitute for effective medical care for individual patients. New York

City is unlikely to replicate the sorts of disease-management programs for patients with diabetes that have been established by large health care organizations with sophisticated information systems and ample financial resources. Although the healthdepartment may help to facilitate diabetes care — for example, by providing patients with smoking-cessation programs, blood-pressure cuffs, glucose-test strips, or low-cost medications — its resources are limited. At present, the health department has only three staff members and a $950,000 annual budget dedicated to diabetes control. Nonetheless, the perfect does not need to be the enemy of the good.If the city’s information system works well and patients’ confidentiality is maintained, the registry initiative could be a first step toward other effective — and no doubt more costly — interventions.

An interview with Dr. Thomas Frieden, New York City Health Commissioner, can be heard at www.nejm.org. Dr. Steinbrook is a national correspondent for the Journal. 1. The Diabetes Control andComplications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med 2005;353:264353. 2. Frieden TR. Asleep at the switch: local public health and chronic disease. Am J Public Health 2004;94:2059-61. 3. American Diabetes Association. Standards of medicalcare in diabetes — 2006. Diabetes Care 2006;29:Suppl 1:S4-S42. 4. Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA 2004;291:335-42. 5. MacLean CD, Littenberg B, Gagnon M, Reardon M, Turner PD, Jordan C. The Vermont Diabetes Information System (VDIS): study design and subject recruitment for a cluster randomizedtrial of a decision support system in a regional sample of primary care practices. Clin Trials 2004;1:532-44.

Becoming a Physician

The Demise of the Physical Exam
Sandeep Jauhar, M.D., Ph.D.

O

ne afternoon, at the beginning of my first clinical clerkship in internal medicine, my team was called to the intensive care unit. A patient, whom I’ll call Mr. Abbott, had just been admitted withexcruciating chest pain that had started a few hours earlier. He was in his early 50s, extensively tattooed, just the sort of tough I wouldn’t want to meet alone in a parking lot at night — but right then he was whimpering. He kept stroking his sternum up and down, as if trying to rub the pain away. It was obvious that he was hav-

ing an acute coronary syndrome. He had all the classic riskfactors: hypertension, high cholesterol level, a history of cigarette smoking. His electrocardiogram showed T-wave inversions characteristic of ischemia. His serum troponin level was elevated. I don’t recall our examining him, but for this most common type of cardiac emergency, there is little diagnostic role for the physical exam. A few hours later, we were paged back to the intensive care unit....