“The high-tech diagnostic testing doesn’t demean the importance of the exam of all,” he says, but its role may have changed.
Are the intricate skills of performing a physical exam imperative, or have they mostly been replaced by technology? “I would say they’re not fully imperative under the assumption that you have the technology and you want to get the job done,” says Dr. Bomback. “Are they desired? Absolutely. A good physical exam and a remarkable finding are about showing what goes on inside the body and manifests itself outside the body.”
The ability to adequately hear a heart murmur or detect tetany is based on the physiologic understanding of why that murmur occurs or how calcium metabolism works. With that in mind, Dr. Bomback believes all patients would want their doctors to have those skills. “But,” he quickly qualifies, “could you have a functioning doctor get through his or her workday without knowing that? Absolutely. Could a cardiologist treat CHF without being able to hear a murmur? Of course. … So it’s desirable, but it’s not totally necessary.”
One reason for the desirability of maintaining those skills, which require physicians to “get up close,” as Dr. Dickey puts it, pertains to the importance of touching, seeing, and listening and to the quality of the patient-physician interaction itself.4 All the physicians interviewed for this article concur that getting that physical sense of the patient will tell you things that other information will not, and involving this true sensitivity in the interaction will most likely put the patient at greater ease.
“Because, in addition to all the information that a physician can discover from doing a physical exam, there is also a sense of rapport that the physical exam builds,” says C. Martin Buchanan, MD, FACP, a hospitalist at Penrose Hospital in Colorado Springs, Colo. “The therapy of being there, being present at the patient’s side, touching the patient, doing something for them, having a kind of healing energy, if you will, that we … transmit to the patient and [which essentially communicates], ‘I’m here to help you, I accept you as a human being even though you’re ill; I’m willing to touch you, and I’m here to help you feel better.’”
Not a Demise, but Compromised
“The physical exam is compromised during patient assessment because of where it ranks in importance,” says Tim Creamer, MD, director of the hospital medicine program at Community General Hospital in Syracuse, N.Y. “There are people who say that history is 80% of the diagnosis, which makes the physical exam 20% of the diagnosis. Although you try to emphasize that diagnostics, such as X-rays and labs, should only confirm your history and physical, we still depend too much on the technology to diagnose for us.”
The physical exam is not emphasized after medical school, says Dr. Creamer, who teaches second-year family practice residents. The emphasis now has become the patient-doctor interface: educating and talking with the patient and family. “And even in the lay literature, they encourage consumers to ‘Get your doctor to spend time with you,’” he says. “They mean talking to you, not checking your neck veins for A, C, and V waves.” Hospitalists may also minimize the physical exam, he adds, “because we feel pressured to maximize the talking and listening.”
The Focused Physical
The newest title in the 2006 edition of the Medical Knowledge Self-Assessment Program (MKSAP), published by the American College of Physicians, “Foundations of Internal Medicine,” includes an extensive discussion about the evidence-based physical exam. A good deal of recent research has addressed the topic of which physical findings are truly important to assess various conditions.