Is it necessary for a doctor to examine you on each visit?

A tug-of-war is going on in medicine right now between the past and the future. The present is confused and very unsure of itself.

Though I could be writing about health care in the U.S and the looming Supreme Court battle over the new health care law, I’m actually raising a much more intimate issue: Whether your doctor touches (examines) you or not.

Many pundits have weighed in on whether the physical exam has utility in an age when we have machines that can look inside the body and evaluate its physiology as never before.

Others have suggested that regardless of an exam’s diagnostic capabilities, performing a physical has intrinsic value: connecting with patients. It’s what they (you) expect. Touch is inherently therapeutic and offers solace.

Medical schools still teach the ancient art of the the physical exam:

  • Inspection. Looking at the patient.
  • Palpation. Touching the patient.
  • Percussion. Tapping the patient’s torso (chest + abdomen) to locate organs and detect extra fluid if present.
  • Auscultation. Listening with our stethoscopes.

These artful skills originated as far back as Hippocrates (though it wasn’t until 1821 that Laennec invented the stethoscope).

Listen to the talk from Dr. Abraham Verghese (Stanford doctor and author of the novel Cutting for Stone) about the rise of the iPatient and his call to return to fundamentals–not only as good medicine but as effective and therapeutic medicine.

Contrast Dr. Verghese’s approach with the experience of Dr. Bryan Vartabedian, a gastroenterologist, blogger, and social media authority from Texas.

Dr. V has a history of herniated lumbar disks. He visited an orthopedic surgeon for a consultation, and this is what he wrote about his visit:

… through the course of my visit he never touched me.  We spent an extraordinary amount of time examining my MRI.  Together in front of a large monitor we looked at every angle of my spine with me asking questions.  I could see first hand what had been keeping me up at night.  I could understand why certain positions make me comfortable.  What we drew from those images could never be determined with human hands.  In my experience as a patient, I consider it one of my most thorough exams.

The contrast between the two experiences and the reactions to them could not be more profound. It leaves me wondering what the most important elements of doctoring are to pass along to my trainees. Losing the physical exam seems blasphemous. Yet sometimes I’ll admit it feels more like hocus pocus than a meaningful endeavor.

What are your views? Is it necessary for a doctor to touch you on each visit? Is a yearly physical crucial? Would a consultation with a doctor be valuable if all you did was talk?

John Schumann is an internal medicine physician who blogs at GlassHospital.

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  • Kathy Nieder

    I try to always touch my patients. Sometimes, it is just a touch on the shoulder going out the door, but frequently it is a heart and lung exam that is completely superfluous TO ME. Patients expect to be touched as part of their examination. It is important to them and I think it helps to remind ME that this is another human being that I am privileged to care for. 

  • http://pulse.yahoo.com/_GPVS3W7KW7HKGZV3BMSKCNHSU4 Kim

    The answer to all of the above questions is “it depends”. Depends on several factors, such as the personalities and desires of the patient and provider, the nature of the problem(s) if there are any, and other factors that are harder to put into words. I wouldn’t suggest that a yearly physical is “crucial”, but there’s certainly no harm in it and there is a chance to perhaps catch important changes in some function or appearance. I also wouldn’t suggest that it’s absolutely necessary for a doctor to touch you at every visit, but it seems to reinforce the human connection that’s often buried under mountains of technology and paperwork in modern healthcare. In the same vein, yes, a consultation where there’s only discussion can be valuable. I’ve had a few of those personally, and at least one of them saved me from an unnecessary surgery. The value of a physician is, contrary to billing practices in the US, often in their wide knowledge base rather than in their ability to do procedures. Yes, both of these are important, but not every situation calls for a procedure. In the example above, it would seem kind of strange to just be staring at images without any exam whatsoever, but there are some situations where perhaps it wouldn’t provide any additional, helpful information. I do think, though, that there should be some kind of physical connection, even if it’s just a handshake or something similar.  For all our technology, we are still human, after all.

    • Anonymous

      I don’t like to be touched and feel a great deal of anxiety being examined.  
      “I wouldn’t suggest that a yearly physical is “crucial”, but there’s certainly no harm in it ”

      The harm of the physical is financial and perhaps that risk of making a patient out of a healthy person.

      • Anonymous

         In my experience, labs and xrays (especially CTs) are more likely than physical exams to “make a patient out of a healthy person”.  I agree that many of the aspects I write down in the chart under “physical exam” are purely inspection, so I do not perform needless palpation, etc. unless I somehow sense that the patient would be reassured by it.

        Similarly, much of the time spent during an “annual checkup” is updating meds and famly history, discussing pros/cons of screening, going through the review of systems checklist, and other “talking” activities.  If the review of systems is negative, I almost never find anything on physical exam that is important, and certainly not anything that requires useless tests.  But I am very proud of the one time I found an apical lung cancer (presented as a subclavian lump) in a smoker that was cured with surgery and did not require chemo or radiation.

        • Anonymous

          ” In my experience, labs and xrays (especially CTs) are more likely than physical exams to “make a patient out of a healthy person”"
          You mean like the screening tests discussed at the “annual checkup?” 

          • Anonymous

             Yes, sometimes THOSE screening tests.  But if I didn’t at least talk about cholesterol panels and paps and colonoscopies (when age appropriate) and something was found later, I would be sued.  I agree that sometimes, results (whether from a lab test or a physical exam) can make a healthy person feel like a patient, but I would argue that in cases where early detection enables us to halt the natural progression of disease and prevent complications, the doctor didn’t “make” a healthy person into a patient, he just found that the healthy person IS a patient.

            In reading all the other comments, it seems like this issue is very polarizing – some people really appreciate the touch and others want it only if absolutely necessary.  I doubt that patients or healthy people will come to an agreement, so all they can do is choose doctors based on their preferences.  Doctors might try to sense what an individual patient might want, but asking directly will probably confuse the patient (or healthy person) or make all physical exams seem too patronizing.

          • Anonymous

            Sometimes screening for disease takes a person who would otherwise never have any issues and turns them into a patient who is now sick and in need of treatment.  Breast and prostate cancer come to mind…where screening can be harmful.

            Studies have shown there is no advantage to having a “annual exam.”  What’s more likely is that the healthy person walks in feeling good and walks out with a plethora of pills and advice that turns them into a sick person in need of medical care.  Maybe it’s better just to be that healthy person and only see your doctor when something is wrong than to risk the unnecessary treatment that awaits you at the doctor’s office.

      • http://www.facebook.com/knasky Kevin Nasky

        This demonstrates the lose-lose situation doctors are in. Everyone is different, and you’ll never make everyone happy. One person’s “therapeutic touch” is another one’s “violation of space.”

  • Daniel H Beegan

    I have two physicians who rely heavily on the physical exam. One was a pulmonologist in Lewiston, Maine, who received her medical degree in her native India, but did her residency and fellowship training in the USA. However, she never lost the skills she learned in medical school in a 2nd world country where not every hospital had a CAT scan, ultrasound or MRI. Currently, I see a DO in Indianapolis who is considered, even by his peers, to be a genius at physical diagnosis. Mind you, neither of these docs fail to order modern tests when they are needed.

  • Anonymous

    if for nothing other than ritualistic reasons, i think the answer to the title is “yes” and i will put my stethoscope on the chest & back of most patients i see, unless there is a clear, focused problem elsewhere like an ankle sprain.

    it is worth mentioning though that a substantial part of the exam falls under “inspection” and even as i take the history i am gathering information that would fall under physical exam. general appearance, skin color, respiratory effort, gait as they are brought into an exam room among other things. so i would argue that there is no such thing as a visit where you don’t examine the patient, unless you are doing visits over the phone which is probably not advisable.

    it is also sad how little weight the exam is given in medicolegal situations.

  • http://warmsocks.wordpress.com/ WarmSocks

    A full exam isn’t necessary. Looking at the patient is.

    I’m okay with my doctor doing whatever is most appropriate to diagnose a problem, even if we’re examining test results.  I’m not okay with a doctor examining the computer screen, though; the patient should be the focus.

  • Anonymous

    I’m with Dr. Verghese 100%.  I had the opportunity to replace a physician who apparently never or rarely examined patients in the clinic.  And who, by report of nurses and patients, cut them off while taking a history.  I have always allowed patients to have a sentence or two, or perhaps more, without interruptions, to tell me why they came.  And, I usually do a focused, or perhaps greater, exam, depending on the situation.  There are times when an exam is not needed(perhaps in a brief folowup), but listening always is.  Sitting down and allowing patients to tell you what is bothering them, or how they feel, is important.  I cannot tell you how many of these patients from that clinic would tell me “Wow, you are thorough”, or “Dr. _____ never touched me”, even when my exam was really pretty focused.  They immediately felt valued, and cared for.  Many of them mentioned these feelings to nurses and front office staff.  The healing power of touch cannot be overemphasized.

  • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

    On the topic of ritualistic actions that have questionable value, when I was a resident, we would assist the private attendings in surgery. Many times, one of the attending’s partners would come into the OR, scrub in, and come to the surgical field, touch the patient for a few seconds and scrub out, allowing us to finish the case with the first attending. By the letter of the law, they could now code and bill assistant fees for the second attending. People will always think of ways to legally game the system within the letter of the law. Watch how this plays out. I predict it will depend on what rules are used to determine what consititutes sufficient examination. Then doctors will find a way to comply with those rules to do what it takes within the letter of the law to legally bill, but not necessarily what grants additional benefits to the patient.

    • John Schumann

      thanks for shining light on a questionable practice. agree with you that we (the ‘royal’ we) are always looking for efficiencies. thus, where we can comply with the letter of the law but also be ‘efficient’ in practice, we can always ‘capture’ maximal charges.

      just another problem with the incentives in piece-work.

  • Ginger

    I had one doctor who would offer his arm getting you up onto the exam table and although I didn’t need any help hopping up I always thought it was a nice gesture.

  • Craig Koniver, MD

    Hate to say it, but it really does “depend”…..why the patient is in the office, how well you “know” the patient…..too many variables…..yes, there is certainly value in the physical exam, but I think it has less to do with actual diagnosis and more to do with connecting to the patient…

  • Anonymous

    As a fellow I saw a patient who came in w/ back and leg pain and a lumbosacral MRI showing disc protrusion causing a lower nerve root compression. He had already seen his primary and 2 neurosurgeons. On exam he clearly had upper motor neuron signs w/ hyper-reflexia (upper and lower extremities) and clonus. Cervical MRI showed a very significant disc protrusion around C5 causing spinal cord compression — and radiology called me w/ it emergently.

    I could never decide whether the other doctors had either not examined the patient, or examined the patient and ignored the exam findings because they conflicted with the MRI (an error of premature closure). And I couldn’t decide which of those options (not examining or ignoring the exam findings) was more negligent.

  • John Key

    I think the “annual physical” or “routine physical” is a pretty worthless examination when done for diagnostic purposes, though the problem-focused exam is often still valuable.  Verghese’s essay, with which i agree fully, really emphasizes the value of the “healing touch” more than any particular diagnostic value.

    I always try to examine, largely to avoid being accused of failure to examine, and to achieve the benefit of the healing touch. 

    The physical exam, like the rectal, is a much overrated test but criticizing it is like criticizing motherhood and the flag.

    • Anonymous

      It all depends who is doing the physical, a new physician each year or your personal Family Physician. The “healthy” at least will come into a physicians office when they are not “sick” for a physical which has saved lives. This gives the physician the opportunity to do age appropriate screening and counseling, comparing the health of that individual to how they were 6 months to one year ago. Personally I have seen multiple “abnormal EKGs” with no symptoms with history of normal EKGs that when tested further their lives were saved. I have also seen a jump of several points in the PSA with enlarging prostate on a man taking testosterone pellets from a physician who is not running these tests lead to a biopsy that showed need to show the patient he should discontinue the testosterone and do the “watchful waiting”.

  • Anonymous

    Over the course of the past four years dealing with specialists, I no longer expect a physician to touch me at each encounter, but at minimum there should be eye contact.  Sitting within 10′ of the patient would also be useful (yes, this means you, Dr. Haughty Cardiologist).

    • Anonymous

      That’s the problem, you are depending on specialists (partialists) to see you as a whole person. The only specialty that does is the Family Physician who still values the interaction with the patients. The good ones will not only look you in the eye, but listen to heart and lungs, do vitals, at every visit even if you come in for them to look at your toes. The reason for this is that if you are healthy you may not come in for some time and they want to make sure noting is missed. Also I bet the Family Doc could order the test and refer you to a better cardiologist, one who will actually send records back to the Family Doc for them to manage your medicine and order maintenance testing. One Doc looking out for you, being your advocate with specialists and hospitals and treating you as the whole person you are.

  • Snax Now

    I worked as a Psych Clinical Nurse Specialist in a small and often quiet government clinic in Texas. I had time to review the pt’s medical record and I noted things that hadn’t been done for years like routine labs . Pts told me they didn’t go elsewhere for tests. I was aghast at what hadn’t been done: No routine screening for years on end, no talking with pt’s about HIV and or if they wanted HIV tests, or screening for other STD’s. No charting of blood pressure or even the taking of blood pressure (I brought in my own equipment from home.) 
    Over the course of six years I uncovered too many cases of syphilis, one case of HIV (ironically the man had to be hospitalized psychiatrically because of the suicidal agitation this bad news caused him, several apparent positive screenings for TB (we were in a very high risk area,) a newly emerged diabetic foot ulcer on a man who didn’t even know he had diabetes (“yes, he said, both of my parents died from diabetes” — an assertion that made me question him further about their pathologies.) In the latter instance the clinic clerks made this individual appointments 3 and 4 months down the line until I intervened, earning me great enmity from them. I’ve found patients with critters, scabies, eczema, and other unknowns (running sores, big pimplels, bumps, and similar nasties) that were beyond my ken simply by looking at them (at the pt and whatever.) Some of these pts were known to be high volume users of our clinic. Those high users seem to have never had their BP taken because I routinely got readings like 180/100, 170/100. 190/100 got a patient taken to the hospital and the Dr murmured about where are the other BP readings. It appears to me that no other clinician, nurse or otherwise, bothered to ask, look, touch, or test these patients in any way about areas significant to their health. One wonders what went on between clinician and patient during their previous contacts.

    • John Schumann

      wonderful comments–and congratulations to you for breaking down that barrier with psychiatric patients. your stories are attestation to the stigmatization of the mentally ill.

    • http://profile.yahoo.com/RRMALYOMAFY7TMPVBW6HXHVCYU M

      You haven’t addressed whether the physical exam is helpful or not.  I suspect that the syphilis and TB you found weren’t due to anything you found on physical exam but rather on screening labs.  You most likely ordered these due to a complete history.  Rarely does anything come up on exam that wasn’t suspected or thought about from the history.  The question is does the physical exam add anything to a thorough history and intelligent ordering of screening tests.  

  • Anonymous

    Not every visit requires a physical exam, for instance a follow-up visit to see how the patient is doing with a new medication.  A new complaint should elicit an exam, perhaps focused, maybe general depending on when the last exam occurred.   However, what really peeves me is the provider who writes in the details of an exam in their note that WASN’T done.  They do it for billing purposes but it is reprehensible.  I have had numerous visits to physicians, read their notes afterward and seen this done. 
    The funniest note was the one where it was written that I have no scars.  I have had 10 surgeries so it is impossible for me to have no scars.  Clearly, I was not examined.  There should be a way to stop THAT practice.

  • Anonymous

    I’ve never understood physicians and others who “auscultate” through shirts (tee shirts, dress shirts, sometimes even jackets), take a blood pressure with the cuff wrapped around the elbow and the stethoscope somewhere on the forearm, never palpate, inspect or even smell.  From sad experience, I can diagnose a superficial pseudomonas infection by sight and smell alone – the lab only confirms what I already know.  Urine, stools, drainage, dressings yield mountains of useful information if only we take the time to use our senses.  Use of the senses is not the same as therapeutic touch, but they are close relatives and in danger of becoming relics of the past – to our great loss.

    • http://profile.yahoo.com/RRMALYOMAFY7TMPVBW6HXHVCYU M

      If you give any credit to evidence based medicine than you would see that the sensitivity/specificity of your physical exam (irregardless of which senses you use) is pretty poor. 

      • Anonymous

        Of course – IF sensory input is the only tool used.  However, as an adjunct to other, more impersonal but scientifically precise forms of assessment, it can be both useful and therapeutic. 

  • http://profiles.google.com/mittmanpa David Mittman

    The question itself is a silly one. Someone comes in for a refill on their  Prozac that they take for mild OCD, no a PE is not needed. Someone comes in who has not been examined in a year or two, yes-take a look. What if you notice bruising in various areas? What about suspicious lesions? Hernia? Anal rash? Tinea on their back? Let alone hypertension, abnormal eye grounds, breast masses and so much more. The exam is a time to touch, to answer questions, to ask questions, to bring up things. 
    I think “laying of the hands” is a bonding between clinician and patient. 
    But hey, I am only a PA. The Ivory Tower people seem to feel this is all “hocus pocus”. 
    Dave

  • http://profile.yahoo.com/XSC6YP5TKZHXFFFUE4CCODMBAI r

    Personally, hocus pocus to me is more like not examining patients. I would say…each time, take it like a new visit. Just last month I caught 2 pts with Afib. When I again asked about palpitations, I opened a pandora box. Dont worry about these ‘social media authority’ you listen to. Do what is right …examine your patients. Applied what you’ve have learned during your training, that’s all!
    Dr. A

  • Anonymous

    I believe that the art of diagnosis through touch is still very crucial in today’s modern medicine. Because we have created the car doesn’t mean we should get rid of all bicycles or horses, instead we should preserve them and find new ways to utilize them for the application of affordable and efficient health care.  It is important to preserve this for various reasons. One of these reasons is this; in a scenario where a health facility is stranded by the inability to purchase advanced  equipment to help doctors diagnose and treat patients, the loss of this art becomes detrimental; and In this case it is most valuable for accurate diagnosis and therapeutic medicine. The value of his art, knowledge and expertise, should not be regarded with the same contempt as an outdated tool, but as a form of medicine that compliments the medical technologies we are fortunate to have at our disposal.

  • Anonymous

    It wasn’t until (after nearly a year of visits) a doctor actually touched my spine, and I nearly went
    through the roof with the pain the light touch caused, that I realised
    how not okay my spine was. To me my back/spine felt “tired” and a bit
    achy but nothing really to mention to my doctor as the more acute and
    intense pain was elsewhere. That physical check incorporating touch
    generated a whole new diagnosis and a relatively simple treatment plan
    which made an incredible difference to my general “tired” lethargic
    body. Not every visit needs a physical examination but certainly more often than it seems to be. You will always get someone who is not above board but on the whole the vast majority of doctors are responsible and likewise it is probably only the odd patient who has an alternative agenda, however, a nurse can always be called in to attend as an observer of technique as
    an extra precaution for both doctor and patient if required.

  • http://twitter.com/drjoesDIYhealth Dr Joe

    Examination is a key part of medicine.However in some instances(depending on the symptoms or reason for visit) it may be unnecessary. That said it is part of the art of medicine to always do some form of examination even if there is no need.

  • http://twitter.com/jablonski002 jaysrin

    America has always been about technology and innovation – a quality that has been admired around the world and which has worked great – the world has been the better for it in many ways because of the countless innovations, particularly in medical devices. At the same time, one needs to acknowledge that extreme techno-centrism, especially in healthcare, has taken us away from the human element. I disagree with Dr. Bryan Vartabedian who finds great enthusiasm in technology to the exclusion of the emotional, the  physiological, and the tactile aspects of care. What a tragedy.
    In India, we have now been experiencing a boom in so-called full body diagnostics  for the past 10-odd years that come in various guises – Master Health Check, Mini Health Check, etc. Hospitals and diagnostic centers market this, employers demand it, and executives embrace it. They range from full packages to specific tests for conditions such as cardio and diabetes. What has been the outcome? Increasingly, doctors are puzzled by two types of discoveries: “symptom-less conditions” where the several tests reveal nothing, but the patient is in distress; and “condition-less symptoms” where a person is obviously fit and healthy but the diagnostics – CT scans or special lab tests – indicate all kinds of problems. If the former is bothersome, the latter brings in its wake a challenge to the attending physician to solve the puzzle, with endless further tests that finally beat the poor “patient” into submission – weak and frail from unhealthy doses of radiation and medication for unproven maladies and the resulting very high out-of-pocket costs. Anyone who doubts this only has to spend some time in a major hospital in the country and discover this for themselves.