The other day, a good friend of mine took his wife to the cardiologist for complaints of dizziness and palpitations. The physician took a short history and said he wanted to order an ECG, an echocardiogram, and some blood work, then started to walk out of the room. At the door, he spun around, walked back, and said, with a chuckle, “I guess I should also listen to your heart,” whereby he did so, through her blouse in two places. (Yes, I know you can hear heart sounds through clothing.)
The director of a PA program recently shared with me her concerns that PA students are losing their physical examination skills in their clinical year, because preceptors are teaching students to use short cuts and rely more on laboratory studies than their hands-on examination skills.
I guess I am old-fashioned. When I went to school—and throughout many years of practice—I relied heavily on my history-taking and physical exam skills to lead me toward an accurate diagnosis. Are we losing those skills? Are we passing them on to the new generation of clinicians? Is technology replacing the need for good examination skills?
Recently National Public Radio (NPR) published an audio report called “The Fading Art of the Physical Exam.” This very poignant report discussed a number of stories in which physicians omitted part or all of a physical examination in favor of an expensive technological test. There are some fears that the trend is likely to get worse. Nesli Basgoz, MD, of the Massachusetts General Hospital, is quoted in the report as saying, “I’m definitely worried that the physical exam is dying a slow death.”1
As a practicing PA for more than 35 years, who has also done his share of both didactic and clinical teaching, I am familiar with this age-old topic and would like to bring forward a couple of points. First, I have learned that a thorough patient history yields about 80% of the information needed to arrive at an accurate diagnosis. That leaves the physical examination to a somewhat, albeit perceived, lesser role.
Secondly, I am convinced that a relevant “laying on of hands” is not only therapeutic but may lead the clinician to a final key to a diagnosis or to further appropriate testing. It never feels complete for me to leave a patient without an appropriate physical exam, whether complete or focused. It is a crucial part of the relationship with our patients that cannot, in my opinion, be underestimated. Now, I’m not saying diagnostic tests are unimportant; they are important. But they should be adjuncts to a proper examination.
On the other hand, Danielle Ofri, MD, suggests “There is scant evidence to suggest that routinely listening to every healthy person’s lungs, or pressing on every normal person’s liver, will find a disease that wasn’t suggested by the patient’s history.”2 It is true that research has shown patients expect a physical exam. So, are we doing it for the patient’s sake or to elicit more data to assist us with the diagnosis—or both? What about the importance of checking for previously missed findings or monitoring chronic disease progression?
There is also evidence that a complete annual physical exam is not cost-effective (assuming that is one of the goals of medicine). Has the focus of medical schools turned from teaching diagnosis using the tried-and-true history and physical examination to using increasingly sophisticated and expensive technologies? If this is true, the skill sets of new physicians in practice may not include listening and physical examination.
The medical profession, and the business element of today’s health care practice, must accept responsibility for the dying art of physical examination. It should be noted, this process of collecting data also includes teaching patients and their community the nature of their problem, what to monitor, and when to call the clinician to intervene. The physical exam encompasses both data gathering and patient education. Touching and listening with documentation will avoid lawsuits, provide cost-effective care, and enhance the clinician-patient rapport.
Since the widespread discussion initiated by the NPR report, a number of respected physicians around the country have called for a renewed emphasis on the physical examination. Abraham Verghese, MD, MACP, has joined with colleagues at Stanford University to publicize a 25-item list of physical-exam maneuvers3 that they feel should be required of internal medicine residents—and perhaps all clinicians. These include everything from funduscopy to knee and shoulder exams to palpation of the spleen. (See medicine.stanford.edu/education/stanford_25.html for the full list.)
In a profile of Verghese in the New York Times, science and health reporter Denise Grady stated, “In an era where lab tests and MRI, CT, and ultrasound machines are the ultimate diagnosticians, old-fashioned physical exams that include careful touching, looking, and listening are at risk of extinction. While some doctors consider physical exams obsolete in light of modern technology, others like Dr. Verghese believe they are a lost art in need of revival.”4