A historical irony—quantitative measurement in critically ill patients is not a panacea

In this issue of the Journal, Ho¹ discusses the results of the EVERDAC (Early Versus Deferred Arterial Catheterization in Critically Ill Patients With Acute Circulatory Failure) trial,² which demonstrated that providing arterial cannulation to all patients who present with clinical shock does not improve their clinical outcome as compared with those who receive cannulation selectively based on the decision of their attending physicians. This finding represents a blow to the concept that having more quantitative objective data always contributes to improved patient outcomes. And it follows decades after an observational study in the 1990s suggested that initial pulmonary artery catheterization using the Swan-Ganz floated catheter does not provide significant benefit to the management of most patients with hypotension (and in fact seems to increase adverse outcomes).³

It is striking that at a time when technology seems to be king (witness the fear of artificial intelligence taking the place of nonprocedural clinicians and the ubiquitous use of point-of-care ultrasonography), the evidence doesn’t support a benefit in routinely obtaining a maximal amount of objective quantitative data, even in critically ill patients. Perhaps the main problem is that we need better directed therapies. But what tools and skills should we be using in making diagnostic assessments and management decisions?

When I was a resident in the early 1980s, there was still an emphasis (and a bit of pimping) around performing an appropriate physical examination. In our intensive care unit at the University of Pennsylvania, I well recall 2 cardiologists, Nate Reichek (a seminal expert in advanced cardiac imaging) and Mark Josephson (arguably the father of cardiac electrophysiology in the United States), who would round with us demonstrating how to obtain and interpret neck vein pulsations and other examination features to estimate a patient’s cardiac pressures. And then we residents would use the available Swan-Ganz measurements, amazed that they usually confirmed our mentors’ physical examination–based estimates and physical diagnoses. I accepted that I would never have their skill, but I believed that there was value in trying. I still listen purposefully to the second heart sound. In my patients with a systemic autoimmune disease, its characteristics may provide a clue to the presence of pulmonary hypertension, and it warrants an internal fist pump to occasionally recognize the presence of left or right bundle branch block based on the physical examination.

One might think that as the Swan-Ganz catheter lost some of its glitter and promise, the perceived value of a well-done physical examination would be restored to its throne. On the contrary, there is a documented, seemingly progressive diminution of cardiovascular system and general physical examination skills in trainees and faculty^4,5 that goes back over a decade. The irony is striking: some major tools that were supposed to render the bedside examination less relevant have themselves failed the test of necessity. Meanwhile, the bedside skills they supposedly would displace seemingly have also atrophied among clinicians (nb, stethoscopes are more effective if not used while listening through shirts). It may well be that the expectations for current technologies, including imaging modalities such as positron emission tomography and high-Tesla magnetic resonance imaging as well as more proletarian tools such as point-of-care ultrasonography, are well founded (but I recall we had the same enthusiasm about the Swan-Ganz catheter). Under some circumstances, are we now less able to both measure and perform a physical examination with confidence that it will make a difference? Perhaps. But we should not consider this a mutually exclusive, winner-takes-all contest between technology and human evaluation as the driver of the clinical decision process. There should hopefully be an intellectual interactive synergy between the two, while recognizing that both have limitations. Without a thoughtful directed physical examination (and history taking), it is quite likely that excess and undirected laboratory and imaging tests (technology) will be obtained.

There is one more important aspect of clinical evaluation that warrants consideration when thinking about technologic tools supplanting the physical examination—the human touch. In the 1990s, when Swan-Ganz catheter use was high and the trend of developing more technologically sophisticated intensive care units was in full swing, the Harvard cardiologist Bernard Lown voiced concern with his statement that “We now practice the laying on of tools rather than the laying on of hands” (discussed in The Lost Art of Healing⁶). Dr. Lown, recipient of the Nobel Peace Prize for his social activism, was no Luddite. He invented the direct current defibrillator (which he declined to patent, feeling that it should be available to all without any restrictions). He and others⁷ recognized that a critical component of successful care of the patient, in addition to the thoughtful use of technology and the laboratory, should be the laying of hands as part of the physician’s therapeutic approach. Appropriately applied, the clinician’s touch can be both an inquisitive tool and a statement of empathy.

So while I fully accept that there are limitations to many of the diagnostic technologies that we have embraced with enthusiasm, and that my examination skills are not what I’d like them to be, I try to remember the significance of that last noted aspect of patient care, empathy. I try to have a hypothesis driving the key features of my physical examination,⁸ and most importantly, I try to perform the examination with a serious intent that both I and the patient are aware of.

• Copyright © 2026 The Cleveland Clinic Foundation. All Rights Reserved.