Doctors are asking whether the physical exam is becoming a lost art

The physical exam – looking into the eyes and throat, taking the blood pressure, sounding the chest – is part of the process of medical diagnosis. It’s one way a physician attempts to determine the cause of a patient’s complaint.

In recent times, doctors have asked themselves whether the physical exam is becoming a lost art. It’s been replaced by an array of laboratory tests and high tech machines that presumably provide greater accuracy than the eyes, ears, and touch of a mere human being. (Smell, of course, also provides clues, and device makers are inventing medical gadgets that detect scents. Doctors no longer taste urine for sugar, as they did from antiquity into the 19th century, nor do they taste perspiration to see if it’s sweet, salty, or acrid.)

The reasons for the current decline of the physical exam are many. Hospital stays used to be much longer, so students had more time to learn from patients. The modern resident’s work week is officially limited, so there’s less time to spend at the bedside. Office visits are now much shorter, and a hands-on exam uses precious time.

The physical exam could completely fade away. It could become a staple only of certain specialties. Or – if it’s viewed as an important component of the doctor-patient relationship – it could experience a renaissance. Its future remains to be seen.

What’s not widely known, however, is that this is not the first time the physical exam has gone into decline. We know from surviving medical treatises that the exam was an integral part of a physician’s practice in ancient Greece and Rome. This continued to be true until the late Middle Ages (1300-1500). The hands-on exam then disappeared for hundreds of years, reemerging gradually in the late 18th century.

There were a number of reasons for this decline, including changes in medical education, a desire on the part of educated physicians to occupy an elite position in society, and a lowering of the social standing of surgeons. A brief look at this previous disappearance illustrates how the practice of medicine is very much a product of the social climate in which it exists.

Hippocrates, Galen, and the humoral theory of disease

We know from the Hippocratic Corpus (fifth to third centuries BC) that physicians were advisedDoctors are asking whether the physical exam is becoming a lost art to dismiss supernatural causes of disease and concentrate on empirical evidence. “It is the business of the physician to know in the first place, things … which are to be perceived by the sight, touch, hearing, the nose, and the tongue, and the understanding.” We know, for example, that Hippocratic physicians palpated the abdomen and thorax. Understanding meant knowing the individual patient as a whole person. To diagnose, one needed to learn the patient’s habits, way of life, work, diet, etc.

The Hippocratic school held that the body was filled with four fluids – blood, yellow bile, black bile, and phlegm – and that these fluids could become unbalanced. Blood-letting, for example, was a way to rebalance an excess of blood. This theory of the composition and workings of the human body was called humoralism.

Galen, a prominent physician who practiced in Rome in the second century AD, continued the Hippocratic tradition of humoralism, adding a greater emphasis on anatomy, physiology, pathology, and logic. He performed dissections — and vivisections – of animals (autopsies were illegal). When Galen palpated the abdomen, he knew the location of the liver, spleen, and bladder. He examined stool samples for color, consistency, and composition. Like his Hippocratic predecessors, he reportedly spent many hours in conversation with a patient as a means of reaching a diagnosis.

We know about Galen’s practices because he left a large corpus of texts that was studied by medical students well into the 19th century. It’s Galen’s theory of pathology – the study and diagnosis of disease – that dominated medicine for almost 2000 years.

Both Hippocrates and Galen were physician-philosophers – theoreticians – but they were also craftsmen. They worked not only with their minds, but with their hands, both to diagnosis illness and to perform surgery. Surgery included the treatment and bandaging of wounds, and, in the case of Galen, procedures performed on the brain (to relieve pressure) and eyes (cataracts). There was, of course, no internal surgery, although there were occasional exceptions, such as removing a bladder stone.

Med school reform and the disappearance of the physical exam

Galen’s teachings were lost when the Western Roman Empire collapsed in 476. They were preserved in Arabic, however, in the Eastern Roman (Byzantine) Empire. Beginning in the 11th century, Galen’s works were translated back into Latin and, by the late Middle Ages, became the basis of western medical education.

A profound change happened at this time – a change that explains the loss of the hands-on physical exam. Medical practitioners separated into physicians and surgeons. Physicians were literate, read (and spoke) Latin, and acquired their medical training in universities. Surgery became a manual craft, learned by apprenticeship. Where previously the theories of the physician and the practical skills of the surgeon had been combined in one practitioner, medicine and surgery were now separate. Physicians were highly regarded by society for their book learning, and surgeons occupied a much lower social standing.

This is when physicians – with a few geographic exceptions – stopped practicing the hands-on physical exam. Scholarship was valued over sensory experience. Reason took precedence over observation. The educated physician valued mental activity and distained manual labor.

In making a diagnosis, the physician gave priority to the patient’s account of his or her symptoms, even if it contradicted what the physician observed with his own eyes. (There were no women physicians, of course.) Patients could be diagnosed through the mail, just as Abraham Verghese writes today about the iPatient who can be diagnosed from electronic medical records with only a cursory visit to the bedside.

The relative social standing of physicians and surgeons

Surgeons became the primary care physicians of their day, attending to patients who could not afford the more expensive physicians. Since this class of patients couldn’t pay very well, surgeons almost always practiced another profession. Commonly they were barbers, but also innkeepers, and later apothecaries (today’s pharmacists).

Educated physicians sought patients among the well-to-do upper classes. Although physicians were more respected than surgeons, they were not necessarily of the same social status as their patients. They aspired to be dignified gentlemen, however, which meant they would not demean themselves by engaging in manual labor. When the stethoscope was first introduced, it was opposed by physicians who viewed its use as a manual procedure. When thoracic percussion was introduced, the response was indifference. Physicians did not handle the bodies of their patients directly.

What physicians did do was observe the general appearance of the patient (especially the face) and note behavior. They took the pulse, not for its speed, but for its quality (similar to traditional Chinese medicine). They examined urine, stool, sputum, and pus, since those specimens provided clues to the internal humors.

By the 17th century, there were thermometers that could measure a patient’s body temperature. Physicians could not find a relation, however, between temperature measurement and a patient’s subjective sense of warmth – a patient could have a fever, but feel chilled. So this new information was considered to be of no particular value.

The advent of scientific medicine

The physician’s resistance to working with his hands or using his senses to make a diagnosis, as Hippocrates and Galen had done, was not just obstinacy or social climbing. It made sense given the humoral theory of the body. Because illness was considered a unique imbalance in each individual, the patient’s account of his or her disease took precedence over what a physician could observe. There were as many diseases as there were patients. There was not yet a concept of the local origin of disease in specific organs or tissues. In humoral theory, diseases could move from one site in the body to another.

In the 18th century, medical education began to associate itself with newly established hospitals, which primarily served the poor. These hospitals provided medical professors and their students with the opportunity to correlate the symptoms of a living patient with evidence revealed by autopsy after death.

This was the beginning of the end for humoralism, which was gradually replaced by the scientifically based medicine we know today. Physicians and surgeons began to attend the same schools and study the same subjects. The sharp division between the two practices began to erode. Once medicine acquired this new understanding of disease, doctors wanted to know as much as possible about the internal state of the body. The hands-on physical exam, aided by new technologies such as the stethoscope, made a comeback.

Fluctuating attitudes towards physicians in the 19th and 20th centuries

Has the rise of scientific medicine had an impact on the social status and professional regard for physicians in our own time? Most definitely.

In 19th century America, there were elite physicians in the big cities – Boston, New York, Chicago – whose patients could afford to pay handsomely. For the rest of the medical profession, incomes were quite meager. Becoming a doctor, however, was a ticket to respectability. A poor boy could apprentice to an experienced physician and become a member of the middle class. (For a woman to be a doctor was quite exceptional at this time.)

Once medicine changed from humoralism to a scientific theory of disease – especially once medicine had something to offer by way of treatment and not just improved diagnosis and prognosis – the prestige of the medical profession was greatly enhanced. Doctors acquired the same status as scientists, who were held in high regard. Vaccines and microbiology brought infectious diseases under control. By the mid-twentieth century, wonder drugs had ushered in the Golden Age of medicine for both patients and physicians.

The Golden Age was all too brief, for patients and ultimately for physicians too. Rapid advancements in pharmacology and high tech imaging in the second half of the 20th century turned medicine into biochemistry and radiology. No longer was medicine primarily the healing art it had been traditionally. Who needs the time-consuming doctor-patient relationship in an era of penicillin, Prozac, and positron emission tomography.

From doctor-patient relationship to medical encounter

Both the physical exam and attentive listening to the patient’s history had provided psychological benefits which were at the core of the doctor-patient relationship. As both disappeared, those benefits were lost. Patients responded with anger, alienation, withdrawal, and disloyalty. They felt free to initiate malpractice suits and to spend more of their own out-of-pocket money on alternative care than on conventional medicine.

In the 1970s, there was a school of thoughtDoctors are asking whether the physical exam is becoming a lost art that argued medicine was turning people into lifelong patients and doing more harm than good. As Edmond Shorter points outDoctors are asking whether the physical exam is becoming a lost art, it’s ironic that, just when medicine finally began to offer life-saving treatments, public regard for the medical profession declined.

It’s not that individual doctors, who were still the same sympathetic human beings they’d been throughout the ages, cared any less about their patients. But the expression of concern for the patient – taking time to know the whole person – was no longer therapeutically essential. The Golden Age of medicine, with its amazing scientific discoveries that turned physicians into demi-gods, ended abruptly when patients stopped worshipping. Medicine became a business and the physician/surgeon just another businessperson.

That’s a bit of an overstatement, I admit. Patients still trust their doctors, and medicine is still a highly respected profession, but there’s a grain of truth there. The change in vocabulary speaks volumes. The “doctor” has become a “provider,” the “patient” is now a “client” or “consumer,” and a “visit” with your doctor – a term that suggests conversation at least, if not the serving of tea – is now a “medical encounter.”

Jan Henderson is a historian of medicine who blogs at The Health Culture.

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  • Susan

    I am a nurse practitioner who makes house calls visits usually to geriatric patients. I am saddened and alarmed at how many patients tell me that “their doctor does not even touch me” during an office visit and “does not listen to my heart [with a stethoscope]“.

    I am also alarmed at the number of reports from my patients that the physician and the office personal use an “automatic BP cuff” to check their BPs and never check their BPs manually. Especially those with CV conditions. In fact they often comment when I bring out my BP cuff and stethoscope about how long it has been since anyone took their BP using these instruments.

    Just pointing out my observations frim the field.

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

      I have written elsewhere about the benefits of a thorough history and physical exam. While some may call it a lost art I call it a neglected part of the evaluation due to expediency. Whether one is in an employed position or in their own private practice the emphasis is on volume and that is unfortunate. Thoroughness takes second place to survival in the under-compensated cognitive specialties.

  • http://www.mdwrites.com md

    As a radiologist, I work closely with emergency doctors. Seems like the CT scan has pretty much replaced the clinical exam. Chest pain= CTA chest. Abdominal pain= abdomen/pelvic CT and so on. The CT scan is so good and the physical exam so inexact in inexperienced hands, that the CT scan has pretty much replaced it for many of these physicians. Also, the increasing demands to see more patients, and malpractice fears has made it much easier to check a box on an order for for CT, then to spend 15 minutes to do an exam.

    • http://www.ServantLawyership.cm Kathleen Clark

      It seems that CTs, often with very high doses of radiation, become the first choice for many physicians, even when, perhaps, not medically necessary. I say that, based on both reading and personal experience. Do you agree? I know you mention that the CT scan is “so good”, but is it often a danger to the patient? How informed are patients before a CT scan?

  • http://patientprivacyreview.blogspot.com/ Joel Sherman MD

    Nice summary Jan. Yes emphasis on the physical exam is disappearing and all the reasons you cite are valid. But to elucidate further, the intricacies of a thorough physical exam are just not as important in an era where x-rays, ultrasounds and MRI’s will almost always be obtained in any ill patient to document the findings. For example, as a cardiologist, it makes less sense to spend intensive time listening to the heart thru a stethoscope when an echocardiogram is more sensitive, accurate and definitive. I miss the era when we would debate physical findings with students; nowadays the physical findings really serve more as a pointer as to what tests should be ordered.

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, MD

    Technology and imaging studies have supplanted hands-on, skilled physicial diagnosis. When was the last time you auscultated an ‘opening snap’?

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

    The history and physical exam should still serve as the basis for creating a differential diagnosis and determining which tests you will need and when. The post by ” md” is descriptive of how tests are ordered in my community hospital ER. It is why radiology is always backed up, inpatients can not get studies in a timely fashion and patients get large amounts of radiation and contrast they may not need. Not every chest pain patient needs a CT angiogram. Not every abdominal pain patient needs a CT of the Abdomen and pelvis despite time constraints and liability concerns. The technology was supposed to confirm or refute our physical findings not replace them. Not taking advantage of opportunities to train future physicians to use their observational and hands on skills is a waste of resources and again contributes to the rising cost of health care. I am sure the day will come when bedside equipment will consist of electronic stethescopes linked to handheld bedside echocardiogram and EKG machines with the data computerized and producing a total picture at the bedside. This doesnt absolve us of our responsibilites as stewards of the profession to teach the students and young doctors how to find those answers if the power is out.

  • Susan

    I understand the comments about ordering diagnostics/advanced testing to confirm a diagnosis – but what about during the follow up office visits? Re: J. Sherman – my home bound patients have the major chronic conditions and sometimes exacerbation of these chronic conditions (CV especially) – and they tell me these stories of “no one touching me” – using automatic BP cuffs – I also teach in various nursing programs and when on the floor with my students – I often see various levels of physicians rounding and the patient is in bed – loud TV – patient gown and covers covering their chest – and the physician comes in – asks a questions – places the stethoscope over the covers and listens to the heart while the patient is answering the initial question – with a group of resident/students observing this…..not everyone but the majority of the time this is the case…….the residents/students are missing out on so much – this is truly sad to see

    P.S. as a young RN I remember the days of rounding with the physician and weekly patient care conferences .. yes things have changed since then but I still think some of these aspects of medicine can still be incorporated into today’s care….

  • Penny

    Some of you seem to have quite high respect for CT scans. I’m terrified of those things. Isn’t one CT scan equivalent to about 1/4 of your lifetime allotted dose of radiation? Isn’t this particularly dangerous for a person who has already had numerous x-rays? Could it be possible that a doctor could be sued one day for exposing patients to too much radiation?
    Seems that a lot of those radiation figures have been hidden from the public for quite awhile now but when you read up on actual exposure in terms other than the “baby terms normally used to keep people in t he dark, such as equivalence compared to trips to Hawaii” it’s actually is quite terrifying.

  • Dyck Dewid

    I’m sensing little consistent genuine, human CARE in the story or in the comments. Except for the comment about touching, this is a subject about career status, operations, greed, self-preoccupation… all cloaked in ‘good medicine’.

    My experience of a ‘good’ physical is my doctor cares about me and listens. Human touch makes it believable, real. That makes me feel good ’cause someone’s looking out for me. I’m reassured.

    To me, care encompasses compassion, love, generosity, selflessness, dignity, empathy, help… Love is actually the only thing that’s important, more than curing cancer or paying the mortgage or keeping a promise. Those who do not have love in their life, or who don’t know what love is are the opposition. But, perhaps only until they experience it.

    Projecting long lasting diseases such as Autism and Alzheimer’s, it seems obvious as numbers increase, that as a society, or medical system, or government, or individually we will soon be overwhelmed financially with their years & years of required care. Some will figure out how to profit. But, most others will suffer. My projection is that individually, and as a society, we will suffer until be learn that genuine care is the way.

  • Penny

    The touching part is indeed really interesting. Has anyone ever “NOT” heard a senior say, “Doctors hate touching old people?” Most seniors, in fact, feel their doctors can hardly wait to boot them out. I suppose that’s because it takes them longer to make their points as well as understand instructions. Not only that, but they also have more ailments and they probably “need” to hear the words in some cases,

    “I’m sorry, but there are simply no safe cures for the type of ailment you have.” Why cause the poor people to come in repeatedly seeking one with false hopes and dozens of unnecessary visits that waste both patient and physician time if none are safe? I really do appreciate an honest doctor versus one with an overly tender bedside manner. Probably most do.

  • http://www.TheHealthCulture.com Jan Henderson

    Dr. Sherman – I’ve recently been reading articles about medical practice in the 1970s, a time when doctors expressed some anxiety about lab tests displacing their clinical expertise. There was concern that reliance on laboratory reports would lead to physicians distrusting their own observations, endangering their personal diagnostic powers. If a definitive answer about the patient can be delivered from the lab, would doctors be less diligent in searching for information that only personal interaction with the patient could provide?

    There was concern about what was happening to the doctor-patient relationship. As early as 1930, a physician visiting an American hospital from abroad commented: “It seems to me that in your enthusiasm for the pursuit of laboratory evidence you have forgotten the patient.” The patient was becoming less a person and more an object of study.

    One observer remarked that an impersonal clinical attitude and a wall of technology were a way to shield the medical profession from the anxieties prompted by critical illness and death, the limitations of medicine, and the physician’s own mortality. Also interesting: The observation that beneath the surface of the modern patient there might be primitive attitudes – a feeling of being surrounded by unknown powers – that were stimulated by the complexity of modern medical techniques.

  • http://www.TheHealthCulture.com Jan Henderson

    I’ve told this story before in comments on KevinMD, but it may bear repeating. It comes from an article in Yale Medicine on the physical exam (http://bit.ly/l1RYKu). A 23-year-old man was diagnosed and hospitalized with a life-threatening pulmonary embolism. He received extensive testing — CT scan, consultation with a hematologist, a coagulation work-up – but the results were all negative. Doctors were unable to identify a cause. The recommended treatment was anticoagulation medication, which would mean this highly athletic young man would have to give up his passion for weight lifting, swimming, and running.

    Then a doctor, noticing how muscular the man was, tried a simple test. The patient straightened his arm, and the doctor felt the pulse at the wrist. The patient then put his arm behind his back and turned his head. The pulse disappeared. When he looked forward, the pulse returned. He was diagnosed with thoracic outlet syndrome, underwent surgery, and returned to his active life.

  • Molly Ciliberti, RN

    “The good physician treats the disease; the great physician treats the patient who has the disease.”
    William Osler
    You can’t treat the patient without examining them and talking with them.