The Physical Examination: Is It of Any Value?
Well, it's time again to teach our first and second year medical students the details of performing a physical exam on patients. But as we do this, there is something in the back of the teacher's mind. What are we actually accomplishing in teaching techniques of the exam? Does what we teach, in practice, provide the doctor with skills that are associated with statistical sensitivity and specificity to make a correct diagnosis? There is uncertainty in this regard, especially since most of what we teach has never been put through the rigorous statistical testing which other diagnostic procedures have undergone. In addition, modern physicians seem to be doing less "hands on" examination to establish a diagnosis and more emphasis on various testing procedures. Well, that is the issue I would like to set for this thread: is the physical exam of any value?
I found an editorial in a 2005 issue of the Medical Journal of Australia written by three physicians Brendan M Reilly, MD; Christopher A Smith, MD; Brian P Lucas, MD. all from Cook County Hospital in Chicago titled "Physical examination: bewitched, bothered and bewildered" which gives a bit of insight into this topic. You can read the entire editorial by going to the above link. The editorial starts out with the following excerpt:
Young physicians today seem confused about physical examination. In the United States, many of them do not know how to do it and do not see why they should. Asymptomatic patients do not seem to need it; the US Preventive Services Task Force found insufficient evidence to recommend periodic physical examination of the breast, prostate, heart or anything else. Sick patients do not seem to benefit much from it either, most of them tested to death regardless of their physical findings. It is hard to say which is the chicken or the egg here, but physical diagnosis instruction in many US medical schools now is either out of date (emeritus faculty members teaching useless arcana like percussion of Traube’s space), out of touch (junior faculty members making rounds in a conference room, not at the bedside), or both.
Young physicians trained outside the US are bewildered about this, too. Many of them, meticulously trained in physical examination, are appalled upon first encountering the “hands off” culture of US medicine. But they learn quickly, in the process often unlearning much of what they had learned before. The pace and clinical impact of this remarkable phenomenon is unknown because no one has studied it, a bewildering thing in itself.
What do you think about the physical exam and your own experiences. Have you been sick but the doctor hardly did any examination? Do you think there is merit in what the editorial's authors wrote later in their editorial 'laying on of hands' improves communication and trust between doctors and patients, somehow 'connecting' them better, not just physically but otherwise." Anyway, I'll be back teaching the physicial examination to the students in a couple of days.. as usual. ..Maurice.
posted by Maurice Bernstein, M.D. @ 11:23:00 AM
4 comments
4 Comments:
A "complete physical" in asymptomatic outpatients appears to be useless. However, when I posted a comment suggesting as much on Sermo.com, I was met with vitriol and told I was a bad doctor even though I cited evidence that most of what we do at a physical is unnecessary. One poster reported he frequently found conditions such as lymphoma, skin cancer, thyroid problems and breast cancer on physical exam. My personal opinion is that likely the majority of those "skin cancers" he found were benign growths, that most of the "breast cancers" led to invasive testing that was unnecessary and caused undue stress to his patients, and that the lymphoma and thyromegaly (if it was actually due to thyroid disease) he found would have been discovered anyway based on review of systems and possibly routine lab work (which also is probably not necessary, but I digress).
In my opinion, we should be spending our limited time talking about things that have been proven to make a difference: advising older women to take calcium and vitamin D, working on smoking cessation, uncovering depression and domestic violence, talking about appropriate vaccinations and screening exams.
We of course can't ignore the "laying on of hands" problem. Many patients are dissatisfied when a physical exam is not done.
A faculty associate of mine discussing this issue of the value of the physical examination brought out some additional points. He notes that physicians performing a spiral CT for acute appendicitis is wasteful not only in terms of resources but also in time. And what does it really accomplish since a perforated appendix in a young woman would still have an effect on her future fertility regardless of how the diagnosis was obtained.
He reminded us that trauma cases often require rapid evaluation and often there is no time for imaging studies.
Physical examination findings contributes to or itself generates a rational basis for ordering or not ordering a study such as an echocardiogram. He implies that ordering a test without a physical exam or the skill to detect an abnormality leads one to the question: "Does everyone need an echocardiogram?"
I doubt every person needs a complete and full physical exam. Every person will, at some time, need a focused physical exam with examination of just those aspects of the body for which the symptoms or other aspects of the history warrant as needed for diagnosis and care.
We must teach our medical students the complete exam not necessarily expecting them to perform this on every patient but so they may learn the skills of observation through eyes, ears, smell and touch. Then, later, they will be able to perform that important focused physical with the necessary knowledge and ability to make clinical decisions. ..Maurice.
My first month as a 3rd year medical student was a fascinating experience. I saw a patient who came in for follow up of an unrelated chronic problem and being very new, I did a thorough exam on him. His belly had a pulsatile abdominal mass, very wide. I couldn't believe it and thought I was catastrophizing by a week later a large abdominal aortic aneurysm was diagnosed and he was sent emergency surgery. I know we have to be wise about how we use our time, but I just can't bring myself to be dismissive of physical exam anymore.
Doc, good for you! (and of course, mostly for the patient). What you experienced is not at all unusual and supports arguments favoring physical examination. In my 50 year career, I picked up a few abdominal aortic aneurisms as an incidental finding but more often carotid stenosis by finding an incidental carotid bruit on auscultation. It gives the doc a wonderful feeling to pick up unexpected findings of pathology on physical exam where therapy may be preventing major chronic debility or even life-saving. ..Maurice.
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