Difficulty of Perfecting the Physical Exam: Vertigo and Beyond

Revised Letter:

We very much appreciated the piece by Lelli et al ¹ on the accuracy—or lack thereof—of senior otolaryngology residents while performing the head impulse test. This is of particular interest given the debate among emergency physicians (EPs) as to whether the head impulse, nystagmus, and test of skew (HINTS) exam should be performed by EPs. On one end, the guideline from the Society of Academic Emergency Medicine (SAEM) strongly recommends that EPs perform HINTS exams. ² However, multiple studies have shown that EPs are poor at performing the exam—including those referenced in the paper by Lelli’s group. ¹ Many EPs use this as a reason to not perform the exam and instead perform (unnecessary) imaging and order consults and referrals. ²

While one could argue that providers of many specialties are often poor at their relevant exams, the HINTS exam is unique in that it is even more accurate than magnetic resonance imaging at diagnosing stroke in patients with acute vestibular dizziness. ³

Yet we know anecdotally that even specialists (who are untrained specifically in acute dizziness evaluation) are often poor at the HINTS exams as well. For example, multiple EPs have been asked by neurologists to perform the HINTS exam on patients who are not even dizzy. A non-dizzy patient will not have the pathognomonic findings of acute vestibular syndrome on the HINTS exam, and will therefore yield an exam that would be concerning for stroke even when one is not actually present. It is therefore critical to know not just how well (or poorly) EPs perform the HINTS exam but also how well or poorly the relevant specialists do. Lelli et al took this very important endeavor to examine their own specialty and found fairly dismal results.

We agree with SAEM that education on the HINTS exam is important. Yet multiple specialties have argued for the importance of learning how to auscultate, do an abdominal exam, etc., with limited results. We have to therefore take into account how the medical system has shifted—and the role of reimbursements. An echocardiogram, for example, reimburses much more than a diagnosis made solely on a physical exam. ⁴ And a complex encounter—made complex with advanced imaging and consultations—reimburses much more than does performing, say, a Dix-Hallpike maneuver; the latter takes significant time yet only reimburses 0.48 work relative value units. ⁴ On the other hand, a shoulder reduction is commonly known to reimburse well; unsurprisingly, EPs are very strong at performing these reductions. ⁵ These figures demonstrate that perhaps time cost relative to financial reimbursement—in addition to lack of education—has impacted the valuation that hospital systems and consequently physicians of many specialties have placed on mastering these maneuvers.

We agree that EPs are not in general good at the HINTS exam. But as Lelli et al point out, neither are soon-to-be independent ENTs. Education is important, but so is a cultural shift toward valuing maneuvers that save radiation rather than the system of always reimbursing more for advanced imaging—whether indicated or not. This is particularly important in the case of acute vestibular syndrome dizziness, where the clinical exam is the gold standard for diagnosis. In addition, we think that vestibular therapists (VTs) can be invaluable for patients who could benefit from diagnostic maneuvers for dizziness. Indeed, at many institutions, VTs are the area experts for these exams, and they have been shown to be excellent diagnosticians. ⁶ For providers who are not yet comfortable with these exams, consulting a VT early can not only reduce costs but can also more accurately yield a diagnosis and—perhaps most importantly—the correct treatment.