Physical exam evidence and whether it’s still useful

A number of respected physicians have called for a renewed emphasis on the physical exam. Perhaps most prominently, Abraham Verghese has joined with colleagues at Stanford University to publicize the Stanford 25, a list of physical-exam maneuvers that they hold should be required of internal medicine residents.

These calls reflect in part the fear that checklist medicine will lead to doctors’ obsession with what Jerome Groopman calls the “iPatient” (the virtual patient reflected in the electronic chart) over the living, breathing person. Groopman writes that medical care in our society “has been recast as if it took place in a factory, with doctors and nurses as shift workers, laboring on an assembly line of the ill.”

The hope that the physical exam might bridge the gap between provider and patient is natural and even salutary, but we should clarify why we think the physical exam is useful. There are several possible reasons: establishing or preserving the doctor-patient relationship in its most elemental form; obtaining data to inform diagnosis or treatment; or even (“merely”) because the patient expects physical contact from their visit to the doctor.

Whether some minimal or “pro forma” physical exam is beneficial is, to my knowledge, not addressed by the literature. Although the periodic health exam (which includes a “tailored physical exam”) is found to have some benefit, the meta-analysis looking at the regular exam did not consider what particular form the physical should take. Maybe this means that the instinct of providers and patients are right: it’s not so much what the physical exam does specifically as that it should be done.

But it’s probably more empirically defensible to focus on tailored elements of the exam in the service of diagnosis and treatment. It’s unfortunate, then, that we lack – or fail to apply – rigorous studies on which parts of the exam work and why. In a review of physical exam checklists used in medical-student education, only about 10% of them used evidence to justify which elements should be included.

There are important exceptions. In Evidence-Based Physical Diagnosis, Steven McGee asks to what extent, and with what technique, various physical exam maneuvers can contribute to accurate diagnoses of particular conditions. The Rational Clinical Exam from the Journal of the American Medical Association (both the article series and the book) asks the same questions. Both books come up with surprising and iconoclastic answers. Even these endeavors, though, fail to cover the entire territory of the physical exam, or even Stanford’s 25 maneuvers. The literature is still haphazard.

But to fully answer the question “(Why) is the physical exam useful?,” scientific evidence isn’t the only kind we need. We need to ask patients why they find it valuable to be examined by the doctor. What do they think the provider is doing? Would they be surprised or disappointed if the physical exam (for good reason) were omitted from a visit? Do they even feel better just from the laying on of hands?

The physical exam, routinely ignored by some and routinely praised by others, is yet another example of an element of the patient-doctor encounter which needs to be taken apart, looked at carefully, and put back together for the benefit of patients and providers alike.

Zackary Berger is a faculty member of the Johns Hopkins University School of Medicine, where he is an internist and researcher in general internal medicine.

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