Monday, March 18, 2013

Worshiping Relics of the Past: The Physical Examination


It seems like every year or so, an article such as this one is published in just about every medical journal either lamenting the withering importance of the physical examination (PE), bemoaning contemporary physicians' indifference to it, inventing creative perspectives to enshrine and hallow it, or just harkening back to the "good 'ol days" when that was "all we had."

The whole state of affairs is ironic and silly, for several reasons.  I would be shocked if the same doctors who hanker after the good 'ol days of Valsalva and Mueller maneuvers, Austin-Flint murmurs and Cannon A-waves don't carry around iPhones, iPads, Up-to-Date Apps, and every other manner of advanced electronic device, aid, and tool.  (They are probably also vocal proponents of EMRs.)  They don't dust off an old EKG machine from the 1960s once a week and teach medical students how to use it just in case they find themselves on a medical mission in Cuba one day.   They use computers and statistical programs to perform calculations for their epidemiological studies, not slide rules and Z-score tables.  If they have a mortar and pestle, or an old microscope, it is on a shelf under various diplomas, testaments to the past and nothing more.  So why all the fuss over the slow but inexorable obsolescence of the PE?

I don't know.  But the reasons usually proffered have something to do with the intimacy of the "hands on" encounter with the patient, the "art of medicine" or some other vague and nebulous platitude.  Absent from these pretenses is any hint that, even if the hands on encounter with the patient is a worthy goal, there might be other ways of achieving it that would be more effective than the PE.  I would wager that, rather than have a physician perform a detailed cardiac examination in 4 positions, most patients would prefer a handshake, a polite introduction, and a few more minutes of conversation.  I also suspect that, if they knew that the examination would add little to the plan of care and that the much more accurate echo was going to be ordered anyways, they would want to know why the physician was wasting his or her time.  Hearing that the answer is "we do this as a way of honoring the way we practiced medicine before technology" would draw skeptical looks if not outright jeers.  "Hey, Doc, did you ride a horse to work too?  HA! HA! HA!"

Indeed, the whole thing smacks of an outdated paternalism, a Wizard of Oz facade that physicians are erecting before patients.  Nowhere in these discussions are any true concerns for the patient perspective on the PE.  Caring for that would require honesty with patients about what we're actually getting out of the PE.  And this is why I tell patients that we don't get ANYTHING out of listening to the heart and lungs daily during follow-up for a confidently diagnosed condition (such as urinary tract infection), and that I'm doing it only because it is a requirement for documentation and billing.  An anachronistic, superfluous, and nonsensical one.  Then I pull up a chair, sit down, and TALK to them.  And often I discover something worthwhile, such as their feelings about nursing homes, the real reason they took an overdose, or the actual amount of vodka they drink every day.

Moreover, insomuch as it is an intimate interaction which violates norms of personal space, patients are permitting it ONLY SO physicians can get useful information out of it.  If it is not for the benefit of the patient, but rather a ritual that a physician performs to honor his forebears or the history of his profession, it could easily be argued from the Kantian perspective to be unethical:  the physician is using the patient as a means to another end rather than as an end themselves.

And that segues to one of several corollaries of this misguided focus on the PE.  The PE, especially the daily PE, I would argue is HARMFUL.  It is harmful because performing it represents an opportunity cost that cannot be ignored or discounted in the calculus of patient care.  There is only so much time to spend, and time spent on one thing means less or no time spent on another.  Not to mention the whole issue of fomites, perhaps the most notorious of which is another relic of the past, the great white coat.

Another corollary is that prior probabilities do not inform the routine exam (which itself often has uninformative likelihood ratios).  Thus, negative results on examination do not rule out conditions for which there should be concern based on priors, and positive results on exam are wont to lead to unnecessary follow-up testing due to low positive predictive value.  It is very interesting to me that we discourage low prior CT scans to prevent discovery of incidentalomas and subsequent cascades of wasteful testing, but we could care less whether the PE leads to the same cascades.  But it does.  The patient is on bedrest (but shouldn't be.)  We sit him up and hear rales.  We get a chest x-ray.  There's a retrocardiac opacity.  Antibiotics are started.  C. difficile results.   We were treating atelectasis with antibiotics and we caused harm.  An alternative approach would be to get the patient off bedrest and ambulatory.  If he's on room air and remains afebrile with no cough and symptoms, no further investigations are warranted.  Not even auscultation of the chest.

Perhaps the most disconcerting thing is that these antiquated notions of the importance of PE have been incorporated into billing and documentation requirements.  There is no requirement to demonstrate that you thought like a physician, that you used your knowledge base and skill set to efficiently diagnose and treat the presenting problem, that you considered prior probabilities or performed any other effortful mental activities.  But you must listen to the heart and lungs if you want to get paid for the encounter.

Nostalgic doctors are at liberty to hanker ruefully for those halcyon days before CT scans, echocardiograms, and MRI machines (and before angioplasty, ACE inhibitors, aspirin, and every other contemporaneous treatment).  But to indulge this wistful nostalgia, I suggest writing a book or teaching a course on the history of medicine, rather than promulgating an outmoded way of practicing.

1 comment:

  1. I agree with the majority of this, but out of curiosity, what percentage of your encounters really require a physical examination for billing purposes? I'm assuming that a majority you are billing critical care time, and for those with 9923x visit codes you do not need the exam if you have adequate history and decision making (though with templates EMR notes, it is MUCH easier to document a detailed physical exam than it is to document a detailed history of present illness!).

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