How the physical exam can affect the doctor-patient relationship

The physical exam is increasingly being overlooked, and replaced by diagnostic tests, which are easier, and take less time, to order.

At this new blog over at The Atlantic, Abraham Verghese talks about how the physical exam, when done well, “earns the trust of the patient, and it also lays the foundation for the patient-physician relationship.”

However, when done poorly, “it does the opposite–it creates mistrust, or even a sense of being disrespected.”

Again, the root of the problem is time, or the lack thereof, in today’s medical practice. Physician time is given no value in how doctors are compensated, so, it’s no surprise that the physical exam falls by the wayside.

But, as Dr. Verghese notes, that is to everybody’s detriment: “I don’t think we even begin to comprehend how much a sloppy exam costs us in terms of missed diagnoses, unnecessary tests, and complications from tests (such as reactions to contrast for a CAT scan) that were never indicated.”

Bingo.

Comments

Barbara Ficarra
Good post. Trust is important for the doctor/patient relationship, and patients crave attention and respect.
Barbara Ficarra
http://snipurl.com/hsyhr
Anonymous
I keep hearing this but am wondering what the solution is. I admit that my physical exam has become much more hastened and therefore more sloppy. But the last time I spent the time to assess a murmur with all the associated maneuvers, it took 15 minutes by itself. With all the anger expressed by patients about waiting for the doctor and wanting to bill the doctor for running late, what are we to do? I would really like some ideas on how to listen fully, do a thorough physical exam and explain the condition in detail all in 15 minutes. And address other chronic issues at the same time. Please help.
Anonymous
“Physician time is given no value in how doctors are compensated, so, it’s no surprise that the physical exam falls by the wayside.”
Doctors claim they spend lots of time worrying about malpractice claims, and there must be significant time involved ordering and reviewing “defensive medicine” tests which they claim they do solely to avoid litigation. Not to mention all the time and money they spend lobbying on the issue.
Given that the relationship with the patient is the key to reducing malpractice claims, it would seem that there ought to be plenty of time to do a proper physical exam and thus improve that relationship.
Anonymous
Having trained in the ’70′s, I am kind of blown away by all this. Skipping the physical would be considered blatant malpractice “back then.” How else are you going to detect an asymptomatic condition?
Example: one of my best friends at age 36 was found to have a significant heart murmur on routine checkup by his family physician. Sent for an echocardiogram, he was found to have mitral prolapse with already moderate-severe regurgitation, and required mitral valve repair within 3 years, still asymptomatic but with LA enlargement and severe regurgitation. Not to mention the 2% risk of sudden death.
So, in today’s world would he have been diagnosed when he became symptomatic and already had pulmonary hypertension? C’mon, guys, are we doctors or not?
anon MD
Anonymous
“. . .what are we to do?”
Either continue to pretend to practice medicine going through the motions and in effect committing fraud while making the most money you can make and letting third parties drain your of your professionalism or refuse to constrained by that 15 minute limit. Who says you only have 15 minutes? Not the insurance company. They don’t care how long you spend. They just aren’t willing to pay you for the time to do it right. Afterall, it isn’t their health. You can take as long as you like. Up to a point you can do it and cover your expenses too–you just have to live lower on the hog.
On the other hand, you can take charge of the economics: Define how much time you need to do the kind of professional work that you can be proud of. Determine a fair professional fee for that time. Refuse to engage in any insurance contracts that do not let you collect that fee.
But to do a sloppy job just to keep the revenue stream where you want it is morally indefensible. A history and exam are the basis of clinical medicine. If you aren’t doing that, you aren’t practicing medicine–you are in some other kind of business masquerading as the practice of medicine.
Anonymous
Anon 9:01 -
I work for a large ggroup. They do determine my appointments. I have to behonest, I am afraid to go out on my own. I don’t have a business degree, I have a medical degree. I am considering switching to just being a hospitalist so that I can spend as much time as I need and the only thing that suffers is the amount of time I am at work. I am find with working longer hours if it means I get to “be a doctor” instead of a triagist/form-filler-outer.
For the record, I do a physical exam but a anything more than a 2/6 murmur gets an echo regardless of whether I do hand grip maneuvers anymore.
Anonymous
ugh . . . the physical–the nasty reification of professional authority of the doctor by which he is able to humiliate and dominate the patient.
of course, evidence based research has found little to any relationship between a regular physical and improved outcomes
then why are doctors so attached to it . . . ah yes, see above.
Anonymous
Anonymous,
I’ve been on sides of the physical and I have to say I like it when a physician takes a little time to actually examine me. Most of the things that an expensive lab workup would pick up can be picked up as effectively with a few minutes of exam. I saw a doctor once who ordered a rather extensive liver workup (only left out the biopsy) and DID NOT examine my abdomen, eyes or anything. Because he was the only doc on my health plan at the time, I decided I would rather be gravely ill than visit him again.
j.
AAFP is discouraging EKG at time of physical. I do not agree as we have saved many lives with that test also which puts the mind of the patient at ease once a year that nothing has changed from their last physical.
Evidence-based medicine is ok if put in proper perspective and is not the end all as it only deals in percentages, which is ok if determining if eye patches help eye injuries heal faster, but not if you are using it to determine whether or not to give the guy who only comes in once a year an EKG.
Is it ok for percentages to be the basis for running an EKG, when you are in the 1% that it would have saved your life??? Does evidence based medicine take into account family history, patient’s early adulthood bad habits, environmental exposures, etc? Every person is an individual, and patient’s peace of mind about their health is just as important as early diagnosis and a comprehensive exam when done well may not help your bottom line, but it will raise patient satisfaction and your outcomes. (Any disease state that is discussed through the lab follow up and during the physical exam you can charge a regular E&M visit code, plus you can charge for EKG, Immunizations, plus get paid for the physical exam.)
God forbid that anyone would believe that Medicine could eventually be boiled down to going to a kiosk at a mall, putting your head the machine pricking your finger and it spits out a diagnosis and a script, just because “evidence-based” medicine states that seeing a physician for a diagnosis only saves 40% of lives.

How the physical exam can affect the doctor-patient relationship

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