Medical students, please read no further.
I am going to challenge one of the bedrock beliefs in
medical training – the value of the physical examination. Indeed, I was taught of the primacy of the
physical exam as a young pup during my 4 years of medical education in New York
City. I believed it and did my best to
acquire these skills from master diagnosticians. Indeed, this was one of the thrills of being
a medical student – learning what those clicks and clacks meant when we
listened to hearts with our stethoscopes, seeing changes of diabetes and other
diseases when we peered into your eyes with an ophthalmoscope or palpating a
pulsating aneurysm that was lurking in your abdomen.
An Ophthalmoscope and Otoscope
The Eyes and Ears of Medicine
I was in awe of these seasoned physicians who could make a
diagnosis just by watching a patient walk across the room.
While I still think the physical examination is useful, I
have found over the years that it is less valuable than I was originally
taught. Years ago, such a statement
would be considered heresy and might risk excommunication from the
profession. But yesterday’s heresy has
become today’s dogma.
In general, physicians consider data from 3 separate
tranches when evaluating patients:
- The Medical History – the patient’s narrative
- The Physical Examination
- Objective Date including Laboratory and Radiology Reports
Medical students have been taught for generations to rely
upon this triad and to regard them as coequal branches of medicine. But they are not. If physicians were asked which of the 3 is
least helpful, I surmise that most would choose to forego the physical
examination. I would be among them. Indeed, it is my view that the patient’s
history is paramount. In most cases, I
can assemble accurate diagnostic considerations after hearing only the
patient’s story. Of course, the history
must be detailed, and the patient given sufficient time to relate it. Interrupting a patient in mid-sentence or not
following the narrative path that a patient creates will not yield a full and
useful history. While less important, I
do find that the Objective Data can be useful in narrowing the list of
diagnostic possibilities or suggesting other considerations. For example, abnormal blood test results
might point to pancreatitis, a condition I might not have suspected as a cause of a patient’s abdominal pain.
The reason the physical examination is the shortest leg of
the 3-legged stool is because it is either normal or has abnormalities that are
not relevant to the current issue. For
example, the vast majority of patients I see in my office with abdominal pain
have normal abdominal physical examinations.
I am not counseling that we abandon the physical examination. And there are certainly cases when the exam is a game changer. But these instances are less common than you might think.
Great commentary! As a medical student in the late 70s/early 80s, I loved doing H&Ps, but promptly went into Radiology. Since then, the physical exam seems to have been nearly supplanted by imaging... good in a lot of situations, but bad in others. Imaging is not perfect, and as you know "suggest clinical correlation" is a huge hedge by radiologists who may not be confident of their findings. So clinicians remaining competent at history and physical exam is still necessary, in my mind. And, as in Radiology, the better you know normal, the more prepared you are to pick up the abnormal! I am a bit afraid for the future, particularly with the advent of more and more mid-level providers that are less trained.
ReplyDeleteIf pre-existing patient with a new complaint,PE is vital to focused and cost-efficient and evidence-based lab/imaging ordering if even needed.
ReplyDeleteIf new patient, relying on someone else's PE may perpetuate erroneous findings or fail to capture an evolving process or a waning process which no longer warrants extensive work up. There is also value in physically touching another person.
Quality focused physical exam remains useful in my perspective.
After seeing 4 patients TODAY who were improperly treated by urgent care facilities and one who was treated by a Good Rx "doctor" over the internet, I couldn't disagree more. Almost every female patient that comes into our hospital ER with any kind of pain in the abdomen or pelvis gets a c.t. with contrast and usually no exam. 64 x rays' worth of radiation and thousands of dollars later they are told the have 'ovarian cysts' which almost all young women have. The physical exam costs nothing, emits no radiation and takes seconds. It is unfortunately a dying art but that is because we let it become so. My instructions to my young colleagues, "touch the patient".
ReplyDeleteAfter seeing 4 patients TODAY who were improperly treated by urgent care facilities and one who was treated by a Good Rx "doctor" over the internet, I couldn't disagree more. Almost every female patient that comes into our hospital ER with any kind of pain in the abdomen or pelvis gets a c.t. with contrast and usually no exam. 64 x rays' worth of radiation and thousands of dollars later they are told the have 'ovarian cysts' which almost all young women have. The physical exam costs nothing, emits no radiation and takes seconds. It is unfortunately a dying art but that is because we let it become so. My instructions to my young colleagues, "touch the patient".
ReplyDeleteAs a neurologist, a careful history and neurological exam are typically superior to reflexively sending someone for imaging. Seems like the younger generation of ER and primary care doctors feel obligated to order an MRI or CT perhaps in part protect themselves legally and/or for “patient satisfaction.“ I suspect they’ve been trained in the thinking that they did not do a thorough job if they didn’t order a test. I can’t tell you how often imaging is superfluous or non-diagnostic. Heck of a lot of wasted resources.
ReplyDeleteExcellent comments all. As I stated in the post, I am not advocating abandoning the PE and state the obvious that a PE can be a critical tool for physicians to use. But my point here is that the dogma that we were taught that a PE is a necessary undertaking for every patient should be reconsidered. I suggest that if physicians over the course of a day or two seeing patients, weigh to what extent the exam adds to our understanding of a case or modifies our recommendations that it's utility will often be found to be wanting. Obviously, there is no risk to a PE, and many patients expect and prefer one, so physicians should be free to examine everyone if they so choose. However, we should not simply pursue practice to meet patients' expectations. Remember when the medical profession 'taught' the public that yearly physical exams were essential, often with labs or an x-ray or EKG thrown in? Thanks to all.
ReplyDeleteThis varies by specialty. Orthopaedic surgeons often rely more on physical exam than on lab or even imaging. A good surgeon knows to treat a patient for possible occult fracture if the history and exam is suspicious, and not to rely on the initially negative x-ray studies. Assessing laxity, assessing a neurological exam, assessing function and a motor exam have no sufficient lab or imaging substitute. One should not consider any surgical treatment without assessment of the soft tissues and a good orthopedic examination.
ReplyDeleteMy orthopedic professor told us during residency that the most dangerous combination for a child with a sprained ankle was a pediatrician and radiologist. Both will often pronounce the patient free of fracture when a careful exam will reveal distal tiibial tenderness indicative of a Salter 1 fracture. I’ve seen it happen over the years, so be careful about trashing a good examination!
ReplyDeleteThe one aspect of the patient evaluation that has declined the most is the most important of all: diagnostic reasoning, due decline in assessment of the patient.
ReplyDeleteLong gone is the time needed to take a thorough history.
Examinaing a patient still has can be beneficial but not today, because of poor examinig skills.
I trained at McGill where I was taught how to percuss, feel for lymph nodes, evaluate for splenomegaly. I have yet to encounter an American medical student who could properly do any of the above. Watson may be better for computing diagnoses, but Watson can't see tears in a patient's eyes or hear a quiver in voice.
Tests are very helpful, but too many are unnecessary, but are ordered anyway because of defensive medicine and diagnostic insecurity.
Diagnostic reasoning thus suffers. Reasoning is also algorithmic/linear today, "if X, then Y",not deductive/hypothesizing. Oh well, Sic Transit Gloria.
The physical exam still matters in pediatrics. Otitis media, pharyngitis, pneumonia, falls and fractures, are all routinely diagnosed with a history and physical exam. Even in asymptomatic patients in a routine physical I have picked up many things from ONLY the physical, from a new-onset heart murmur to scoliosis to a football-sized ovarian tumor. Don't be fooled into thinking that just because the physical is a low-yield procedure that it has lost its relevance.
ReplyDeleteI agree with all commenters. There is no question, and I have so stated in the post, that the physical examination can be a critical diagnostic tool. And there is certainly no risk in performing it. And I agree that many patients expect to be examined. But my own experience, reinforced by telemedicine encounters during the pandemic, informs me that for many cases, the history and data review are sufficient to craft a rationale treatment plan. This opinion may apply more to some specialties than others. For example, a dermatologist must examine every lesion. However, think of all of the patient encounters that we skillfully manage on the phone or after hours. We must feel confident enough to proceed without requiring that these patients come to our office or to an urgent care clinic for an exam. The exam is an important tool that may be targeted to specific clinical circumstances like all other diagnostic tools. I'm not advocating that physicians should or must abandon it. My point is that in many cases it does not add meaningful data. Ten years ago, the medical community would have railed against the prospect of telemedicine arguing that it is simply not possible to treat patients remotely. Now, telemedicine is here to stay and many physicians have been among its strongest advocates.
ReplyDeleteI still think the physical examination is vital to the whole picture. The problem is, because of time constrictions, people differ or abbreviate the exam. This is unfortunate. Often the detailed history obtained from the patient will help you focus on certain parts of the exam which are important.
ReplyDeleteTelemedicine in is a good addition, but I believe its usefulness is in the assessment of the patient to help decide if they need to be seen and when, most of the time. It also gives the physician more information than just a phone call to make these types of decisions. Although at times a more focused exam is called for, actual hands-on patient evaluation is a necessary part of medicine. Relying on tests is one of the reasons medical costs are so high. Unfortunately, the current state of medicine is what has contributed to how medicine is practiced today.
ReplyDeleteAs one of the developers in telemedicine in the early 90’s. We wound up realizing after numerous focus groups that telemedicine was valuable evaluating patients incarcerated, very rural areas where limited access to physicians exists and if the world was affected in a pandemic.
ReplyDeleteThis is what we identified in 1992
I agree that not all specialties should emphasize PE, but I will never forget what one of our engineers said..”Doc, for some things we like anonymity like a phone call, but when I feel sick, when a doctor laid his hands on me, I felt my body healing.”