How important is a doctor’s skill in the physical exam of a patient?

How important is a doctor’s skill in the physical examination of a patient?

To the lay person, a doctor’s examination might seem really important.  “Of course it is, Dr M … Come on.”

But is it so?  Or, perhaps, is the examination a charade, a show, a necessity to complete the medical record.

It turns out that many in the profession think doctors may be losing the skill of palpating and listening.  At least NPR said so recently, in their piece on the fading art of the doctor’s exam.

Does a mastery of physical exam skills really help us to be better doctors?  What’s the real impact factor of the physical exam?

Such is a tug-of-war, where the older generation (let’s call them seasoned physicians) who think they can palpate gallbladders, pull against the new generation of doctors who are equipped with ultrasound skills and i-stat lab machines which can (in minutes) determine the patient’s left atrial pressure or hemoglobin concentration. Is the redness of the conjunctiva (lining of skin inside the eye) really that important when one can quickly know the hemoglobin concentration with a pin-prick of blood?

But surely there must be an intangible effect of the doctor who expertly and compassionately palpates, observes and listens to the body’s whispers. I have felt this myself, when I was a patient.

The stethoscope felt cold on my back. He was going through the motions of the exam; I knew this and he knew that I knew. The problem at hand was geographically distant from my heart, but I knew that listening to my heart valves click open and closed was necessary to complete the consult.  As in this day and age, for a consult to be compensated, enough bullet points have to be noted. I wasn’t paying him to exam my heart. When he started listening to my heart, I thought, “you know, I am a cardiologist.”

But then, during the exam, a funny feeling came over me.  It was a comforting sensation, like I was being checked over with thoroughness, and care. I knew there was nothing wrong with my heart or lungs, but the hands and attention felt right. It was both intangible and real at the same time. “He’s a good doctor,” was the sensation I felt.

In the real world though, we only have a precious few moments to take a history, do an exam and explain the many possible treatment options.  If care is “patient-centered” we have already spent much time listening to the patient’s problem, their perception of the problem and any associated socio-economic contributing factors to their problem.  That’s a lot to do in our allotted time — especially if the patient is an engineer.  Do patient’s want the intangible of the doctor’s touch, or a detailed explanation of the treatment options?  Oh, and I almost forgot the increased time it takes to fill out the 4-page medical record, which used to be just a minute or two to dictate a personal letter to the referring doctor, but now is something so electronic, so sterile, so awful.

Take as an example, the bedside evaluation of atrial fibrillation (AF). (But for the sake of argument, you could substitute a myriad of other diagnoses, like cancer, diabetes or obesity.) You have reviewed the patient’s records. There is an ECG that shows AF, or a biopsy that shows cancer, or a blood sugar that shows diabetes.  The diagnosis is certain and the patient needs something done more than just a nice physical exam. In AF for example, you know they will need an echo, not for cover-your-butt purposes, but rather for real-life treatment decisions, like in good medicine.  When an echocardiogram is done, or to be done, the auscultation of the heart tones seems eight parts pomp and two parts circumstance.

The NPR story singled out echocardiograms as an example of “expensive” tests that doctors order indiscriminately. It was a horrible example. Healthcare costs are not spiraling upward because of too many echos. To treat AF correctly, a non-invasive, painless and really not-that-expensive ultrasound is appropriate. Plus, as DrRich points out, echocardiograms really don’t have to be as costly as they are. (But that’s another really long post in and of itself.)

Back to the patient-centered model.  The patient-encounter time clock is ticking. There isn’t a lot of time to play around with gait analysis, eye-exams and tuning forks.  Doctors who are masters of the obvious know this.

So, how much laying on of hands is needed for good doctoring?

It varies, as it always does in the real, un-electronic world.  Like when the nurse-practitioner comes out of the room frazzled, and tells me to put on the white coat before I go in.  This patient may need more exam.  Or, you may need more physical exam when you are in the rural clinic without an ultrasound machine or nuclear camera.  Wait, that’s a bad example; even rural clinics have these technologies now.

The real story is that in pure objectiveness of findings the physical exam is eclipsed by modern technology, by a bunch.

But in forging a trusting relationship with the patient the examination still holds great value.

Just don’t waste too much time with the tuning fork.

And get everything documented, even those pale conjunctiva.

John Mandrola is a cardiologist who blogs at
Dr John M.

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  • http://www.hopestreetgroup.org/index.jspa Joy Twesigye

    Being able to balance appropriate exams and appropriate tests in a 6 minute visit is important and difficult. A physical exam should be important not because it makes someone feel better but because it is relevant and appropriate care. What some practitioners do in an hour others can do in 20 min. I’m focused on the health outcome in either case. When we put all our eggs in one basket or let some skills rust without outsourcing them to those who retained them—one risks a surprise. You can get replaced. Franchised minute clinics have primary care providers clamoring. Online communities replace vetted health educators. If Costco started selling ultra-sound machines….I would love to see the instruction videos on You-Tube.

    I worry that you are making the case that the people who go to years worth of training are functionally irrelevant. The tests can’t interpret themselves. If your accu-check machine reads 10 but I’m having a great conversation with you I know enough to check for a mechanical problem before shoving some glucose gel down your throat.

    For sure, there is equilibrium somewhere.

  • http://www.healthecommunications.wordpress.com Steve Wilkins

    Sir William Osler (1849-1919), considered the “most influential physician in history,” believed that the best diagnosticians were those that listened to their patients. The following quote attributed to Osler says it best – “Listen to the patient – he (or she) is telling you the diagnosis.”

  • Beth

    I personally dislike anyone unnecessarily touching my body. I don’t feel more reassured or “cared for” when a doctor does a hands-on exam as opposed to some sort of lab or imaging exam. I hope that, in my case, no doctor would go through the charade of a hands-on exam on the grounds that it is always comforting to a patient.

    But when I had abdominal pain and several doctors palpated me and found nothing amiss, and then a surgeon palpated me the same week and within seconds identified two abnormal masses (which turned out to be malignant, as he suggested), I couldn’t help but be impressed.

  • http://ryanmadanickmd.wordpress.com/ Ryan Madanick, MD

    Thanks for this article. The devil’s advocate view, however, is that many physical findings have poor test characteristics (sensitivity, specificity, accuracy, etc), as well as limited inter- and intra-rater reliability. In the era of evidence-based medicine, we need to be truthful about the limitations of our own skills as well.

  • pj

    “you may need more physical exam when you are in the rural clinic without an ultrasound machine or nuclear camera. Wait, that’s a bad example; even rural clinics have these technologies now.”

    Not sure if you mean rural cardiology clinics but rural primary care clinics sure don’t have them. I rotate thru 10 CHC’s in underserved areas and not one of them has an xray, much less U/S. Most of my pts are the ‘working poor” and can’t afford outside referrals for such tests.

  • http://www.BocaConciergeDoc.com Steven Reznick MD

    Listening and taking a careful and thorough history is essential. The physical exam is used to supply more data when
    building a theory , hypothesis or differential diagnosis. The history and physical can be used to direct appropriate use of technology. Mitral Valve Prolapse was proposed as an entity by Dr Barlow based on exam. He was ridiculed by his peers until the phonocardiogram confirmed the click murmur. Then early use of the echocardiogram by inexperienced techs and physician led to over diagnosis of the condition in patients where the physical exam did not support the diagnosis. Its a balance the use of listening , examining and technology. To lose those skills cheapens the profession !

  • Finn

    As a patient, I really appreciate it when my doctors can diagnose (or rule out diagnoses) through physical exams. I’d rather not be exposed to unnecessary radiation when my internist can examine my foot, ask me questions, watch me make certain motions, and determine that it is not broken. I’d rather not be sent for an expensive test and have to pay the deductible when my doctor can gather the clinically necessary information by listening to my heart, palpating my abdomen, or examining my eyes. I appreciated it when I asked her if a sleep study would give her any useful information about my long-term insomnia and she told me it wouldn’t, and when she later changed her mind because of a new symptom. I think it’s important for doctors to learn and maintain many of the skills required for a good physical exam and not just rely on expensive technological tests. Of course some old skills become obsolete–no one needs to taste a patient’s urine for sugar any more–but any that still provide clinically useful information should be maintained.

  • horseshrink

    If there is a belief that imaging “must” be done anyway (silent attorney staring over the shoulder), why invest time in a physical exam?

    A doc can get through more patients by skimping on the physical and farming out a more definitive evaluation to techs/radiology.