The physical exam is useless

I have written before that the physical exam is useless in American medicine:

This is why the physical exam is useless in American medicine – it cannot hold up in court. Clinical evaluation and judgment skills now needs to be supported with objective, and often expensive, tests. Here we have a case of three separate physicians who, in their clinical opinion, did not feel a CT scan was warranted. They relied on clinical judgment. They were sued and lost. What is the moral of the story? Order an expensive test and save yourself the trouble.

Today, the NEJM has an excellent piece on the demise of the physical exam:

It may be true that doctors today are busier than ever and have less time than ever to examine patients. It’s true also that a physical examination often is inaccurate. But these facts only partly explain its apparent demise.

The primary explanation, I think, is that doctors today are uncomfortable with uncertainty. If a physical exam permits a physician to diagnose a herniated spinal disk with only 90 percent probability, then there is an almost irresistible urge to get a $1,000 MRI to close the gap. The fear of lawsuits is partly to blame for that urge, but the main culprit is the fear of subjective observation. Doctors shy away from making educated guesses on the basis of what they see and hear. So much more is known and knowable than ever before that doctors and patients alike seem to view medicine as an absolute science, final and comprehensible.

Of course, technology itself can be inaccurate, its results irreproducible. Moreover, the readings from our machines must always be filtered through our eyes and minds, where, inevitably, they are contaminated by the very subjectivity from which we have been trying to escape. Even finely tuned electronic instruments may not offer absolute and decisive truth.

These days, I am sometimes asked to teach physical diagnosis to medical students. When I do, I try to put the realities of modern medicine – the technology, the time pressure, and all the rest – out of my mind. In my everyday practice of physical diagnosis, I am a bit of an agnostic. Of course, I dutifully apply my stethoscope to my patients’ chests, but I do so often simply out of habit.

We already have robot doctors making hospital rounds. In the near future, doctors won’t have to even touch their patients.

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