The ART of the Physical Examination
Written by Editor   
Thursday, May 22, 2014 04:31 AM

Some in healthcare are concerned with a growing phenomenon that some prominent medical educators say has become increasingly commonplace as medicine becomes more technology driven – the waning ability of doctors to use a physical exam to make an accurate diagnosis.

In most hospitals today, the average amount of time a busy intern spends with a patient is 4 minutes.  No longer are tests ordered based on the results of a careful physical exam and history,  but the technological tests become the primary source of information on the patient. It's backward now, and the process is driving up healthcare costs and subjecting patients to the risks posed by sometimes unnecessary, risky procedures. The current system is so ridiculous and inefficient and expensive that we're going to have to go back to doing some of the old stuff.  Doctors trained outside the U.S. are much better clinically than young American doctors. They are trained -- or forced by circumstance -- to rely less on technology and more on physical diagnosis skills.

There is general agreement that the technological explosion that began in the 1980s led to the decline of bedside skills, and insurance that pays for tests but gives short shrift to a careful and time-consuming history and physical exam accelerated the trend, as has the growing paperwork burden doctors face.

The generation of influential mentors who taught physical diagnosis has largely retired. Even bedside rounds -- where such knowledge was often imparted to impressionable neophyte physicians -- are mostly a thing of the past, migrating from a patient's hospital bed to a conference room down the hall where test results and the chart -- not the actual patient -- are examined.

Too often, physical exam skills are dismissed as inferior relics of the past when compared with "the glitter and perceived objectiveness of modern technology," said Steven McGee, a professor of medicine at the University of Washington and the author of a recent textbook on evidence-based physical diagnosis.  McGee said that studies have found that physical exam findings can be as accurate as their technological counterparts.  Case in point: A pair of studies involving 185 acutely dizzy patients found that the presence of certain abnormal eye movements were more accurate than an initial MRI scan in distinguishing a serious stroke from a benign inner ear problem.  The enormous amount of technology that doctors now must master has crowded out physical diagnosis, he said. But, he noted, "there is a giant chunk of diagnosis that still depends on what we see and detect" through observation and a physical exam.

Information gleaned from inspecting blood vessels at the back of the eye, observing a patient's walk, feeling the liver, or checking fingernails can provide valuable clues to underlying diseases or incipient problems, they say.  But over the past few decades the physical diagnosis skills that were once the cornerstone of doctoring have withered, supplanted by a dizzying array of sophisticated, expensive tests.

A lot of people downplay the physical exam and [wrongly] say it's fluff, but in many cases in which technology, unguided by bedside skills, took physicians down a path where tests begot tests and where, at the end, there was usually a surgeon, and often a lawyer. Sometimes even an undertaker.

To address the problem, programs to revive and teach physical diagnosis are underway at some medical schools. The programs are predicated on a belief that these skills are an essential adjunct to technology and can boost diagnostic accuracy, curb unnecessary and expensive testing, and foster a greater connection between patients and doctors, many of whom spend increasing amounts of their day staring at their computers rather than looking at the patients they are treating.

There are two reasons it remains crucial to do physical diagnosis at least as well as doctors did 100 years ago.  We can catch the obvious diagnosis that one can miss at great cost to the patient, and the physical exam also represents an "important transactional moment" between doctor and patient -- a laying-on of hands that helps foster trust. An increasingly common complaint from patients in the medical community is that "the doctor never touched me."

Overreliance on technology has produced perverse results. "If you come to our hospital missing a finger," one doctor quipped, "no one will believe you until we get a CT scan, an MRI, and an orthopedic consult."

Some components of a physical exam are familiar, such as listening to the lungs and heart, and assessing blood pressure and pulse. But other parts may be less familiar. Below are some of those beside tests:

  • Feel lymph nodes and differentiate benign enlargement from possible malignancy.
  • Evaluate patient's walk for signs of neurological or musculoskeletal impairment.
  • Inspect the tongue for the presence of infection or underlying illness.
  • Feel the thyroid gland and palpate the spleen to check for enlargement.
  • Assess the liver, checking for tenderness and enlargement, and recognize signs of liver disease elsewhere in the body.
  • Evaluate tremors and involuntary movements.
  • Examine fingernails for signs of kidney, heart or lung disease, or nicotine use.
  • Check shoulders for range of motion.
  • Evaluate knees for pain and movement.

The complete list of twenty-five recommended evaluations is available HERE

But some experts are skeptical that reviving the physical exam is the best approach in the 21st century.  Taking time and energy to train doctors in the physical exam may be less valuable than teaching them how to communicate or to analyze … data.  These days, medical students often train on actors who are only pretending to have medical problems.  Recently a doctor enlisted her husband, who has a bad knee, as a featured patient. Many students told her they had never seen a patient with a knee problem. "When we bring in patients with real pathologies, the students are very excited about that," "We have to show them that this is worth their time and demonstrate how much information you can gain" through a good exam, which is not intended to replace technology but to guide its use.