The physical exam is useless

I have written before that the physical exam is useless in American medicine:

This is why the physical exam is useless in American medicine – it cannot hold up in court. Clinical evaluation and judgment skills now needs to be supported with objective, and often expensive, tests. Here we have a case of three separate physicians who, in their clinical opinion, did not feel a CT scan was warranted. They relied on clinical judgment. They were sued and lost. What is the moral of the story? Order an expensive test and save yourself the trouble.

Today, the NEJM has an excellent piece on the demise of the physical exam:

It may be true that doctors today are busier than ever and have less time than ever to examine patients. It’s true also that a physical examination often is inaccurate. But these facts only partly explain its apparent demise.
The primary explanation, I think, is that doctors today are uncomfortable with uncertainty. If a physical exam permits a physician to diagnose a herniated spinal disk with only 90 percent probability, then there is an almost irresistible urge to get a $1,000 MRI to close the gap. The fear of lawsuits is partly to blame for that urge, but the main culprit is the fear of subjective observation. Doctors shy away from making educated guesses on the basis of what they see and hear. So much more is known and knowable than ever before that doctors and patients alike seem to view medicine as an absolute science, final and comprehensible.
Of course, technology itself can be inaccurate, its results irreproducible. Moreover, the readings from our machines must always be filtered through our eyes and minds, where, inevitably, they are contaminated by the very subjectivity from which we have been trying to escape. Even finely tuned electronic instruments may not offer absolute and decisive truth.
These days, I am sometimes asked to teach physical diagnosis to medical students. When I do, I try to put the realities of modern medicine – the technology, the time pressure, and all the rest – out of my mind. In my everyday practice of physical diagnosis, I am a bit of an agnostic. Of course, I dutifully apply my stethoscope to my patients’ chests, but I do so often simply out of habit.

We already have robot doctors making hospital rounds. In the near future, doctors won’t have to even touch their patients.

Comments

Anonymous
I can’t stand being touched with whom I have contractual relationship (except of course if I’m in Bangkok on a business trip)
yes, it is possible that machines can do a better job than doctors can. the evidence isn’t in, but it does seem suggestive.
the problems are 1. Kevinmd feels useless; well, too bad, luddite.
2. Expense–this is a problem with third party payer systems. If people had to PAY for their CT scans and MRI, there would be fewer of them. Go high deductible HSAs. That’ll solve the problem
Anonymous
Technology in this profession has gotten way out of hand, obviously we can’t handle it.
I’m in my mid 50s so I remember the days when I was a child of going to your Drs. and NEVER being sent for tests or to a specialist. If you were sent to a specialist then you knew you probably needed to get your affairs in order. My grandparents lived their entire lives without seeing Drs. on a regular basis. When they did see one they were REALLY sick. You went to the Dr. paid about 2.00 for a visit and got all your medicine (in little paper envelops) while there. No ins. papers to file, no pharmacy to go to, did not cost a weeks wages for the office visit and it was hassle free. They lived into their mid 80s. When the ins. companies got involved in medicine it went south.
Now there are Drs. to admittedly order tests just to break the system? So, when my co-pay went through the roof this year because of rising ins. costs, I can blame my physician for that? You know, all those tests he ordered and worry he put me and my family through because he is mad at a system….Talk about BS.
Dr. Kranky
I can assure you that physical exams are alive and well among certain specialties like orthopedics or otolaryngology. In fact, if you query such specialists you will find an almost universal disdain for IM and FP colleagues who seem to have forgotten how to do something as simple as examine an ear or examine an ankle. Nothing is funnier than watching a referring doctor get an ultrasound to diagnose a cystic lesion in the neck that a first year resident in Oto can pick up by palpation.
Paul A. Hoadley
“yes, it is possible that machines can do a better job than doctors can. the evidence isn’t in, but it does seem suggestive.”
Huh? You seem to be missing an entire layer of reality here. Except in some fairly specific cases, machines don’t make diagnoses. Take the example of the herniated disc mentioned in the post. The MRI doesn’t come out with the pathology circled, or a line which reads “Diagnosis: herniated disc”.
Anonymous
Dr. Cranky,
Thanks for the good laugh. It is similarily hilarious when an orthopedist or ENT cannot write a temporary refill for a BP med, or sends a patient with a bp of 150/100, or someone with muskuloskeletal chest pain, or benign abdominal pain, or whatever simple 4th year medical student problem to the ER. Or won’t admit a trauma patient to their service that has isolated injuries to their area of the specialty. Oh, and don’t call me until you have reconstructed axial and coronal CT’s, and have clearance by neuro, neurosurg, trauma surgery, internal medicine, pulmonology, cardiology, and have coordinated care with the plastic surgeon and Ophtho.
And to Mr supersmart who keeps harping that the high deductible HSA’s will solve everything. Good luck. I do hope it will help. People for the most part are too short sighted. They don’t worry about the catostrophic illness but do expect not to have a copay for every prescription and little whim they want to se a doctor for.
Like a broken record — It is about liability, rationally, and irrationally. In the original article the doctor is certainly irrational. I don’t defend it
HMO’s have tried to reward doctors in the past who limit resource utilization. The cry from the consumer was that their concerns were being dismissed to “save a buck”
Maurice Bernstein, M.D.
I think that if the interest in performing a physical exam is waning is because the time to take a complete history of the present illness is too short. A physician needs to take a good history and simultaneously developing a differential diagnosis in his/her mind to make the physical exam interesting and valuable. Doing a physical, hoping that the physical exam itself will provide a diagnosis, is a futile exercise. What makes doing a physical helpful is to use it to contribute towards the support or ruling out a specific diagnosis. If that student in the article had only thought the history of chest pain, beyond a myocardial infarction also included dissecting aorta, then the absence of blood pressure reading in one arm would have been highly suggestive of such a diagnosis. Without that diagnosis in the differential suggested by the history, the absent blood pressure becomes only some sort of an error.
It’s history,history,history and developing a differential diagnosis as the history is obtained that will make the physical exam a worthy exercise. ..Maurice.
Anonymous
There’s no money in the physical exam anyway, is there?
It’s ironic how many physicians are big Bush backers, considering the way he has devalued your services.
Anonymous
I just got home from an ER shift where I saw approx. 6 patients an hour, including an intubated 7 week old. History and Physical exam? You’ve got to be kidding me! I’m trying to avoid lawsuits on 50 charts I signed tonuight. All I have time to do is order tests, and admit as many as I can so some poor schmuck resident can figure the patient out in the middle of the night.
Anonymous
Funny Dr C but in my experience I never see an ortho admit without a medicine consult and I almost never see ENT as an admitting service period. The disdain goes both ways.
Dex
“In the near future, doctors won’t have to even touch their patients.” Hmm, where have I heard about that before…
http://en.wikipedia.org/wiki/Image:Doktorschnabel_430px.jpg
This plague doctor has a “gas mask” with a snifter filled with spices and herbs such as orange cardamon and mint (still being done today, I think–think diabetic foot) to ward off the smell of people dying, and a “death stick” with which to prod people to see if they’re alive. That guy is the forefather of allopathy.
-Dex
Flea
I’ve wondered for some time about the emotional impact on the patient of extra imaging and testing.
My empiric observation is that it makes them more nervous and anxious, not less.
I know the bean counters and the lawyers don’t care about this effect, but I do and I know the patients do.
best,
Flea
Anonymous
“My empiric observation is that it makes them more nervous and anxious, not less”
If you were in a raped specialty like mine I think you’d worry a little more about your own butt and a little less about theirs. Just this week I’ve had 2 patients tell me they are suing me, an average of two a week tell me that, it’s usually crap. One told me she was suing me because I wouldn’t refill her narcotic script, forcing her to go back to street drugs, which, she said, I would be responsible for.
diora
I wonder if the parents who want unnecessary cat scans for their kids are told that these CT scans can cause cancer later in life?
I cannot possibly imagine how any parent would insist on a CT scan for their kid if a doctor were to tell them “this has such and such chance of causing cancer in that many years”. My mom would’ve probably needed to be convinced why it is necessary in cases when it really were rather than insist on it “just in case” like some American parents do. But then I grew up in another country…
Americans seem to be in love with technology; they also have an almost religious belief in prevention like it is going to make them immortal somehow (some people they seem to believe more in having extra tests than in non-smoking or eating less… but this is another story)
Anonymous
Dr. K,
No need to be self righteous. I think it is a problem in all specialties. My father was having a severe time with allergies and nasal polyps. One of his complaints was severe ear pain. He got a CT scan and “endoscopic” evaluation at the office. Total bill about 2500$. When I asked him what he said about the ear he said “Oh he never looked into it”
RL
From my perspective as a patient, I feel I’ve gotten the best medical care when a doctor has used the combination of my history, a physical exam and results of tests to figure out what the problem is.
I have an interesting saga about a herniated disc and spine MRI’s. Several years ago, I went to my family doctor because of burning pain in my lower legs. I told her that I thought I had a problem in my ankles, since the pain was the worst there. She told me that I must have a disc problem, and a CT scan showed a small herniation at L5.
Four years, four neurosurgeons, one rehab specialist, two MRI’s, a myelogram and numerous treatments later, no one could figure out why I had the pattern of pain that I did, or why no treatments worked, especially considering that all I had was a small disc herniation. Finally, a second rehab specialist, after looking at all my films, taking a history of my symptoms and carefully examining my lower legs, decided that I had a nerve problem in my ankles called tarsal tunnel syndrome. An orthopedic surgeon recently operated on one ankle, and found a band of tissue sticking to the tibial nerve there, which was entrapping the nerve and causing the pain.
I’m not angry about this whole affair; I’m more puzzled about why so much weight was put on the spine MRI’s, and so little on the history of my symptoms and on doing a careful exam. I certainly hope that physicians don’t give up on doing the latter two things; I know in my case it made all the difference.
Maurice Bernstein, M.D.
RL, please complete the story. What happened to your symptom after the surgeon unstuck your tibial nerve?? ..Maurice.
Paul A. Hoadley
“I’m more puzzled about why so much weight was put on the spine MRI’s, and so little on the history of my symptoms and on doing a careful exam.”
It’s not a huge puzzle, and, in fact, the originally-linked article answers the question—it’s because clinicians are being forced to practice defensively for fear of being sued. (You just happen to be an atypical case because you weren’t also demanding the investigation be done just because it happens to be possible.) Once the MRI occurs, the temptation to use whatever information it provides is just too great—and in your case it was also misleading.
You provide an excellent example of the danger of not just over-testing, but testing at all in the absence of a comprehensive history and physical examination. When the test performed is not completely sensitive and specific, Bayes tells us that the prior probability of the diagnosis (that is, how likely the diagnosis was prior to the test) affects the interpretation of the result. Roughly, if you’re performing something other than a gold-standard test (such as MRI lumbar spine for burning ankle pain), you better be pretty sure you know the diagnosis before you perform the test.
Anonymous
“And if you want to debate the admissions thing I’d be glad to do that too.”
Sure Dr “K” I would love to. Did ENT’s not go to medical school? Is it that hard to write for a patients home medications and have some idea what PRN medications are needed in HTN? I am not talking about serious medical issues needing a medicine consult Dr. “K”. I am talking about surgical subspecialties who have no clue how to manage BASIC medical issues even to the point of writing home medications. I know it is easier to “dump on medicine”, but as I said before the disdain goes both ways. I know the basic ENT exam but in my experience no ENT has any interest in any medical issues to the point where I work I almost NEVER see ENT admitting patients period. End of story.
Anonymous
PS: Maybe you need to keep your insults on whole medical specialties to yourself Dr K. Trust me I can’t tell you how many “obvious” medical questions I have recieved from ENT’s.
Anonymous
If I were an ENT I certainly would not disparage my referral source that probably makes half as much money while working 25% more hours. If I got a consult that was simple I would enjoy comforting the patient and thank my lucky stars that I never went into primary care.
Dr. Kranky
Candor is what’s lacking in our profession. I’ve no fear of “disparaging” my referral sources because nothing will change about your referral behavior. This article on the demise of the PE is more proof. You may not like what you hear but you can’t deny it’s truth.
And please: spare me the lame comebacks about how people like me won’t refill a script for a drug which I’ve not prescribed, for a disorder I don’t treat What a sin! Wouldn’t the patient’s PRESCRIBING doctor want information on whether he/she is taking the med as prescribed? How does me interjecting myself into that chain help matters? What happened to concept of continuity of care. I’ve always been told that was the Holy Grail of general medicine.
And to one of the Anonymi: thank you for taking me down a notch. You’re right- there is no reason to get self-righteous. It DOES happen in all specialties. I’m sorry your relative got a very expensive and poorly focused eval. It DOES happen all too often in this procedure oriented specialty.
And yes, the other critical issue in diagnosis is good history taking. I’d hate to see that go by the wayside as well. It saddens me tremendously to hear a teaching internist state that he pulls out his stethescope for the moral edifcation of his students, and not because it is valuale tool is his armamentarium of the PE.
Anonymous
About the comment I expected from a doc who never manages patient’s in the hospital.
RL
To Dr. Bernstein,
I only had ankle surgery 5 weeks ago, so it’s too early to tell if it worked or not. The orthopedic surgeon told me it could be several months until the swelling goes down, and the nerve heals, before anyone can tell if it worked or not. I knew this going into the surgery.
Dr. Hoadley wrote: “You just happen to be an atypical case because you weren’t also demanding the investigation be done just because it happens to be possible”
You are correct. I didn’t want to have the initial spine CT scan and tried to convince my family doctor not to send me for it. I tried to convince her that something was wrong in my legs, and I even had her examine my ankles. I also tried to convince her not to send me to a neurosurgeon. To even get an appointment with the neurosurgeon, I had to have a spine MRI, which is why I ended up having one.
The third and fourth neurosurgeons did notice the inconsistancy between the pattern of pain I was reporting, and the pattern that would be expected with having an L5 herniation. I’m not certain why they didn’t consider that I might have a problem in my legs, rather than a spine problem.
The rehab specialist who figured out I have an ankle problem told me that he had problems with heel pain. Perhaps that’s why he focused on examining my lower legs so much, and had some knowledge of the ankle condition I have.
Anonymous
Dr. K. does not do much to buck the stereotype of self righteous and self important specialty surgeon does he? Impressed that he knows more about cystic lesions in the neck than you?
His best excuse at ignorance outside of the neck is “Someone else should want to do it”. Huh?
I doubt he is turning off the lights in the exam room and transilluminating sinuses. No, I am sure he is ordering CT scans and looking endoscopically while charging ridiculous $$. Why?,because it is better technology. Likewise, listening with a stethoscope for heart murmers is largely a waste of time when echo is better technology. What a boob. He must be the same ENT that takes call at my hospital. In five years of practice I have probably called ENT into the ER 5 times to actually see a patient. Mind you, they have extorted a stipend for the hospital for having their name placed on the call list. Last time I called he said, “You really ruined my day, I was just going out for a bike ride”. If I were responsible for what the patient presented with I would go find a nosebleed everyshift that won’t stop with bilateral anterior and posterior nasal packing just so I could ruin his bike ride.
I agree, the topic at hand is history and physical. As one smart patient saidabove, the H and P is one important tool that should guide you to order technologic tests wisely so you know how to interpret the results in proper context.
Anonymous
You’re an angry little person.
Anonymous
“Wouldn’t the patient’s PRESCRIBING doctor want information on whether he/she is taking the med as prescribed?”
Would that be the ER doc who told the patient to call an ENT, or maybe a neurologist who saw the patient first (on referral from the ER) and referred on to the ENT? Of course after an MRI and CT Scan. What you’re missing, Kranky, is that Family Docs and Internists are a dying breed and most patients that get referred in my “hood” are given your phone number by an overwhelmed ER doc. You better relearn your primary care medicine cause the patient you see next week probably won’t have a “personal physician”
molly
Kranky asked for more candor. There you go.
Anonymous
LMAO LMAO
Yeah kranky I will remember your pontificating the next time I get a 02:00 “stat” c/s from an ENT for a BP of 155/95. You self-rightous baffoon.
Laurie Anderson, RNP
Heh heh, most of you are such fine displays of medicine in these posts that it’s no wonder people are turning to nurse practitioners for compassionate, holistic care.
Fortunately for my patients, my greatest mentor in the art of medicine, a D.O., taught me that identifying the correct diagnosis is at least 50% good history taking, that having phenomenal physical assessment skills and using them is critical, and that tests are used to “confirm,” a diagnosis.
Someone has to stop the litigation insanity somewhere. Telling patients that you aren’t doing a test because they don’t need it at that point is fine. Telling them you will consider that test later if they aren’t getting better is reasonable, thoughtful medicine. The problem with this approach of course, is that it requires thoughtful, effective communication with your patient. I think these posts demonstrate how that goes sometimes…
Anonymous
Oh please Ms. NP. I have no problem with Doctor extender’s, but the fact is you are working under an MD’s license (in most states). I can tell you just as many times when a patient specifically refused to see an NP because they wanted to see “the doctor”. With respect to “holistic” care, as long as it is evidence based, then I have no problem. The problem is when “holistic medicine” is practiced with no evidence to back it up. Think about it.
Luklinski
Physical examiation is crucial in diagnosis of spinal disorders,85%tests are useless,mri ,scan -clinically MEANINGLESS.Medicine as practised today is a clinical QUACKERY with USA BEING A WORLD LEADER in FRAUD spinal surgery .
rgds, B.M.Luklinski( Mr )(MR ),WWW.SCIATICASOCIETY .ORG

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