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Sunday, October 17, 2010

The Physical Exam

The New York Times has taken note of Abraham Verghese's efforts at Stanford University School of Medicine to revive the art of examining patients. One gets the idea in this article that most medical schools have let the entire subject slide, which is not true. Nevertheless, enthusiasm for the hands on aspect of data gathering has declined somewhat. When I was in training about 25 years ago, my clinical teachers took the subject of teaching us how to identify pathology in a patient seriously. Johns Hopkins medical school was at that time held up as a model of a clinical teaching institution, so training medical students and residents in the arts of examining hearts, blood vessels, livers, spleens, bones and joints was clearly going to be part of the curriculum. Many patients who moved through the clinics and hospitals associated with Johns Hopkins donated important pieces of their time and dignity in the service of teaching what would be generations of physicians how best to do this. When I finished my training, I felt confident enough to continue to teach myself these skills as I treated and examined 10s of thousands more patients.

The perceived value of the physical exam, however, has taken many hits in the years since I graduated.  Well known and oft quoted studies showed that even specialists in liver disease could not tell the difference between belly fat and fluid in the abdomen, that cardiologists couldn't agree on the identity of the many heart sounds associated with failing hearts and valves, and gynecologists were unable to identify ovarian cancers by physical exam at a stage when it had an impact on survival. Many doctors began to back off on the level of intensity of their examinations, partly because they were not entirely sure whether they believed what they saw, felt or heard in a patient's body. Technology such as CT scans, MRI scans, x-rays, ultrasounds and mammograms became much more universally available, and we began to rely on them more. Very little was said about the fact that these, too, are inaccurate in many cases, and only now are we beginning to recognize the fact that both the radiation and the costs associated with these tests carry a significant toxicity.

A good examination takes some time. It doesn't necessarily take much time, but in the hands of a doctor who is not comfortable performing it, the choreography is tricky. In large practices where doctors are expected to see patients at 10 or 15 minute intervals, there is not enough time to have a patient undress and be examine, document the findings, order the appropriate tests and prescribe the appropriate medications, especially if the physician is expected to actually speak to the patient about what is going on.

Teaching the physical exam is part of the art of medicine. Over the years that a doctor practices, he or she will see many presentations of many diseases and develop theories about what findings are indicative of things such as prognosis, response to treatment and subtleties of diagnosis that were never a part of their training. If that physician has an opportunity to teach, these pieces of knowledge will be passed on to students who will further cultivate it based on their experiences. Many of the "clinical pearls" that are developed in this way can never be scientifically tested, but will have immeasurable value.

Much of the information I get from examining a patient, looking in mouths, listening to hearts and lungs, feeling thyroids and lymph nodes, doesn't influence my diagnosis or treatment of a patient, except due to lack of unexpected findings. As a betting person, since the majority of physical exams are normal, I might choose to simply not do them, and assume that they are normal. It would save a lot of time. But without a physical exam, the two of us, me and the patient in the room, are just talking heads, telling interesting stories. Humans are made multisensory creatures, and our communications are best when they include all of our senses. Even the crudest of my senses, my nose, tells me information that is valuable. The touch of hands to skin is a communication that involves two, and the information flows both ways. A patient can sense my confidence, empathy, skill or lack of it. Facial or body movement in response to my hands tell me what kind of problem, how serious and how the person being examined handles illness.

I appreciate the fact that Dr. Verghese is tackling our lack of enthusiasm for the physical exam, bringing his obvious joy in the subject together with his charismatic teaching style to get a new generation of doctors excited about what they can do with their own hands, ears, eyes and noses. Those of them that teach will undoubtedly allow his gift to keep on giving.

This is a link to the article on Dr. Verghese in the New York Times:

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