Orthostatic Vital Signs: Much Ado

Dr. Bob Centor has inadvertently started a cute little brouhaha over the measurement of orthostatic vital signs (pulse and blood pressures on the same patient taken while standing, sitting, and lying supine) that Happy the Hospitalist has eagerly jumped into. As usual, Dr. Bob is right, and Happy goes off like an idiot. (Dr. RW’s comments in support of Dr. Centor are spot on, also as usual.)

There are two different issues being discussed that are being incorrectly conflated:

1. The value of orthostatic vital sign measuresments, and
2. Who should be doing them, nurses or doctors.

Let me begin by saying that I have no dog in this fight, because the entire discussion is moot to my practice. Ever since my last medical assistant threw a hissy fit and walked out several years ago, I’ve been doing it all. Weighing and measuring patients, doing EKGs, drawing blood (plus spinning it, completing requisitions, and packaging specimens for lab pickup), as well as all vital signs. In my office, there is no such thing as “nurse’s work”. I do everything.

Measurement of vital signs is part of the evaluation of the patient. Delegating the task to non-physicians does not change this fact. I agree that in many settings, it is efficient and appropriate for nurses and others to perform many patient evaluation functions, including so-called routine vital signs. But a physician should never feel it is “beneath him” to do them. There is also a fine line between so-called “routine” patient evaluation maneuvers, as many consider vital signs to be, and, say, the more subtle procedures that constitute the physical exam. For example, nurses often assess for the presence or absence of bowel sounds, but few of them have the training or skill to detect shifting dullness or a fluid wave. I suspect Dr. Centor would be equally dismayed to see “abdominal exam” relegated to the status of an admission order.

I rarely do orthostatic vital signs, just as I don’t often check for shifting dullness. I reserve them and other specialized maneuvers for appropriate clinical scenarios. To do otherwise would not be an efficient use of my time. Specificity and sensitivity of orthostatic findings in syncope patients is an interesting discussion, just as whether or not the finding of a fluid wave can quantify ascites. The issue is that of tailoring our evaluation to the clinical presentation. (Perhaps this was Dr. Centor’s lament?) I’m sure many people, like Happy, no longer bother with abdominal exams (we already know he doesn’t do rectals or pelvics; I wonder if he bothers with the neuro exam before the brain MRI?), because everyone’s getting a CT anyway. I agree with Dr. RW that this attrition constitutes dumbing down of clinical medicine, and I strongly agree with Dr. Bob that the physical examination is not scut work, regardless of how many of his commenters feel otherwise.

If you as the physician feel that measurement of orthostatic vital signs will add to your assessment of the patient, you should be performing them yourself.