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Is the physical exam necessary?

September 2010

I listened with bemusement to a recent NPR piece exploring the apparently fading importance of the physical exam in medical education. The feature points to the growing primacy of medical technology as the reason why the skills that physicians have used for centuries to diagnose illness and initiate treatment plans are vanishing.

I remember one of the first books I bought in medical school was Mosby’s Guide to Physical Examination, a required bible for students. With its countless pictures and detailed descriptions of things like murmurs, McBurney’s point and Roth’s spots, this book made an ancient idea in medicine concrete: that your senses are all you need to take care of your patients.

But apparently now, the physical exam is becoming passe.

I’ve noticed this creeping “technologization” in my own practice. I often look at a set of lab values or x-rays before ever laying eyes on the patient. It is a morning ritual that is part preparation for that educational “golden moment” of rounds, and part making sure that the residents and students are following up on things and actually know what they are talking about. In fact, sometimes this assessment of ancillary data supplants the actual laying of hands on the patient.

I admit that, after a few asthmatics and bronchiolitics, listening to wheezing loses a bit of its educational significance. Then there is the ever increasing pressure to decrease length of stay and score “excellent” on patient satisfaction surveys that frankly have nothing to do with the actual quality of the medical care we deliver. Instead, they say more about the quality of the steps (and missteps) we take to deliver “care,” whether “care” is defined as actual therapeutics, comfort, or how clean the floors are or how bad the food tastes. All these factors contribute to the findings in a recent study that suggest hospitalists spend less than 20% of their time in direct patient contact.

So where did the physical exam go? Has it become a nostalgic notion supplanted by more important deliberations, as Dr. Bob Wachter alludes to in the NPR piece? Or is it an invaluable ritual that establishes the necessary trust in the patient-physician relationship, like Dr. Abraham Verghese pointed out in the article?

I joke with my colleagues that one of the reasons I am more efficient than they are in terms of time management is that I don’t examine the patients. Realistically, the “laying on of hands” serves more than just a diagnostic purpose. Patients notice our body language, our attitude, our tone of voice. They notice if we don’t sit down, if we are in a hurry.

And they notice if we do or not examine them. Just yesterday, a mom remarked on the fact that I stood in the doorway instead of putting on the gown and mask required to enter the room. To the patient, the image of the doctor is still that of a human being delivering human care, not an automaton going through preprogrammed motions to dissect, subtract, visualize and prescribe.

Medical technology has helped many patients endure injuries and conditions that were unsurvivable just a few decades ago. But that does not mean that medicine is all about technology.

Like Dr. Edmund Pellegrino, professor emeritus of medicine and medical ethics at the Center for Clinical Bioethics at Georgetown University Medical Center, wrote many years ago, “Medicine is the most humane of sciences, the most empiric of arts, and the most scientific of humanities.” The physical exam is surely part of that connection between medicine the science and medicine the art. To lose its relevance would relegate physicians to the ranks of technicians, and medicine to the level of a trade.

And our patients, while grateful for the exacting imagery of x-rays and the prodigious wizardry of medical and surgical procedures that save their lives, will surely miss that human touch.