A connection is lost when we outsource the physical exam

I remember my first visit home at the end of my second year of medical school. I’d just received my black doctor’s bag loaded with medical equipment. Like a 16-year-old with a new driver’s license, begging to do the very errands she’ll soon groan about, I went around my parents’ living room and took everyone’s blood pressure, looked in their ears and throats — and then made my “rounds” again.

While I never got tired of doing physical exams, they did, of course, lose some of that initial thrill.

But now that parts of the exam are being outsourced to other caregivers, I miss them. And I find myself feeling not so different than I did on that spring day so long ago when I asked, “Can I take your blood pressure, please?”

Nurse practitioners and physicians’ assistants do annual physicals, hospital admissions, and preoperative medical clearances. Medical assistants take blood pressures and perform other tasks previously done routinely by physicians.

There are good reasons for a team approach, including current and projected physician shortages, especially in primary care, and pressures on physicians to crowd many patients onto their schedules because of low Medicare and other reimbursements. Many argue, reasonably, that some jobs must be offloaded to give doctors more time to be doctors — to diagnose patients’ problems, formulate treatment plans, and offer counseling about how to prevent illness.

But I sometimes worry that we could be losing something important.

For example, measuring blood pressure offers an opportunity to touch a patient, one I’m not sure we doctors should be so quick to abandon. Many times I have seen a patient for a consultation — say, to discuss birth control or assisted living or an imminent divorce — and capped the visit by taking the patient’s blood pressure and listening to their heart and lungs.

In over 20 years in practice I have never yet had a patient ask me why I was examining them when their problem wasn’t “physical.” Touching a patient is part of paying attention to them, of caring for them.

The physical exam has another, harder to define but no less important benefit: It makes me feel more connected and attuned to the patient.

Recently, my practice adopted the common procedure of having a medical assistant take the patient’s blood pressure after escorting him or her into an exam room.

But I keep forgetting about the new procedure, and start my exam by taking the patient’s blood pressure.

Last week, as I wrapped the cuff around her arm, a patient said: “Oh, someone already did that.”

I said, “I know, but somehow I can’t stop taking blood pressures myself.”

The patient, a thoughtful young woman, asked, “So it’s like a ritual for you? Like breathing before yoga?”

And I answered, “Exactly!”

Suzanne Koven is an internal medicine physician who blogs at In Practice at Boston.com, where this article originally appeared. She is the author of Say Hello To A Better Body: Weight Loss and Fitness For Women Over 50

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  • Chris OhMD

    I agree. Unfortunately the trend these days is that primary care does very little in terms of procedures and refer most to others. I do my own blood draw not only because I’m very good at it but as this article points out it keeps me connected to my patients. My patients love it – most patient do no like seeing one doctor then having to go somewhere else and wait an hour for a simple blood test.

  • Robert Bowman

    Nearly all schools have already outsourced clinical skills training. When you teach at a school that focuses on the chief complaints (scheme presentations) as the framework for the curricula, a school where clinical skills and osteopathic skills are taught to facilitate the clinician framework during the first week and all weeks of training, you realize many things.
    First, you realize your own weak skills and it takes you 1 or 2 years of such dedicated training to be able to teach such skills.
    Second, you realize the sad decline of the past 100 years in skills and other foundational areas.
    Third, you begin to understand some of the root causes of too much done at too high cost with more consequences – due to lack of a clinician foundation.
    Fourth, you become frustrated with leaders and accrediting bodies who do not “get it.”
    Fifth, you separate true clinicians from those who are not capable – MD, DO, NP, or PA.
    Sixth, you are training graduates that can practice anywhere – including 30,000 zip codes where 65% of the population is left behind in lower to lowest workforce concentrations where consultants are rare and where you really shine in clinical skills and must, because there are few to fill in gaps.
    Clinical skills is not an add on late in physician training. It should be a part of admissions evaluation for candidate selection and a part of the first training and all parts of training – by design. Clinician Specific Medical Education

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Doing an exam and touching is part of every visit. Keeping skilled at performing a history and competent physical exam should be part of every discipline in medicine. Passing it on to those training is part of the stewardship aspect of handing off to the next generation of care giver that is necessary and supposed to be part of the professional credo.
    Insurance companies kidnapped medicine and contributed to the changes in training that have limited teaching of these skills and it came with the blessing of employers, HR departments and politicians seeking campaign contributions. Professional bureaucrats at places like the AMA , ACP, ABIM, JCAHO, CMS have further decimated training while they reap huge salaries taking physicians and staff away from the bedside and relegating them to chasing around additional bureaucratic regulations that do little for safety and the training of broadly trained practitioners and do much to increase their personal wealth.

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