Many are bemoaning the deterioration of physical exam skills that the current generation of doctors are displaying.
Bob Wachter says it may not be that big a deal. “Even if we could create a new generation of expert physical examiners,” he writes, “would it be worth the time and trouble?” He doubts it, saying the time spent to learn and perform a comprehensive physical has to be “weighed against cold-hearted considerations of accuracy, reliability, inter-observer consistency, and the cost of time.”
Technology has the potential of making parts of the physical exam obsolete. Traditionalists may be arguing for staying with a horse and buggy when cars are rapidly becoming available.
Dr. Wachter instead suggests more time be spent on “timeless” patient communication skills, like “eliciting the history, describing prognosis, discussing alternative treatments, determining the patient’s attitudes about end of life care, and apologizing for medical errors.”
In addition to technology, a whole host of other incentives are shifting emphasis away from the physical exam, not least of which are malpractice fears (where an objective study would pull more weight in a trial than a subjective physical exam finding), and the financial pressure to maximize the quality of services (which devalues the time spent doing a physical exam).
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My very healthy son had to have a state-mandated physical for 11th grade (Pennsylvania), a state-mandated physical for his driver’s permit, a state-mandated physical for a worker’s permit, and now a mandated physical to enter a state college. I’m thinking some kind of simple waiver system after the first physical could free up a lot of GP time.
Abstracting meaning from paper charts or EMRs without validating against a real patient/customer is something that google and its kin will be doing better and faster as time goes on. Patients/customers will have to take a more active role in their health management, facilitated by more and better tools. Doctors should take care that their value add doesn’t become perceived as marginal to these new aids and holistic perspectives outside the guild.
Chuck Brooks
FutureWare SCG
I’d like to point out this section:
“The structured physical examination still fulfills a legitimate need. When approaching a patient with an ill-defined, potentially multisystem disorder, the examination should provide an initial “staging” of the disease process that contributes to the construction of the differential diagnosis, and thus refines the ordering of specific tests.”
Here is the original article, it worths to read it:
http://www.ccjm.org/content/75/4/257.full
I also have posted few things in my rarely updated blog, please allow me to cite the page:
http://iskanbasal.wordpress.com/category/clinical-examination/
I also think about the importance of some pages like the “image challenge” published periodically in the NEJM and how this is important in learning the skills for performing a carefull search for signs and symptoms.A great contribute to the issue discussed here in this post could be those many articles published on JAMA under the title :”THE RATIONALE CLINICAL EXAMINATION”.
An echo might be worth a hundred cardiologists, but one cardiologist can keep you from ordering that very expensive test. Kevin recently posted an NYT article that talked about the abundance of tests that are being ordered and the results that can be difficult to interpret. Ten minutes with a cardiologist can determine that an echo isn’t necessary – that appointment might cost 1/10 of what the echo would cost. I think there’s an enormous amount of value in the PE.
Anon 3:05 pm:
In my area, most referrals to a cardiologist end up getting an echo and/or stress test.
cardiologists don’t keep tests from being ordered, they drive the huge number of tests.
Docs I know all like to retake the blood pressure themselves with a mercury thingy. They don’t trust the automated ones of their expensive machines.
As Jerome Groupman points out in his book, “How Doctors Think,” its a fallacy to believe that radiology results in better diagnosis than medicines backbone, the history and structured physical. As Groupman points out, radiologist are actually quite inaccurate, and basing diagnosis on low resolution black and white images is silly. Further, medicine has always been about the doctor patient relationship, and its lack of ability to cure most diseases.
I cannot believe the value of the physical examination is being called into question here… I really hope none of you are my doctor because your ignorance WILL cost lives… what about the MAJORITY of diseases and syndromes that are diagnosed on a CLINICAL basis, you know, the diseases for which there are no tests to make an accurate and timely diagnosis…
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