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Indeed, the whole thing smacks of an outdated paternalism, a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.
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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