“If internists will pay attention to what’s in the medical literature about reliable physical findings,” says Dr. Buchanan, “we can tailor our physical exam a bit better, make more efficient use of the [interview] time, and provide very useful information for our diagnostic assessment and treatment planning.”
The MKSAP-14 offers 11 print books, a CD-ROM, and a new online version. Information is available at www.acponline.org/catalog/mksap/14/.
Powers of Observation
Performing a good physical exam is “something that we all aspire to and something we always try to improve,” says Dr. Bomback. “Anytime I hear of someone with a good physical exam finding I will try to see that patient.” It’s one of the reasons he likes working in an academic center. “There are always interesting cases, and there is always someone who wants to teach someone else what they’re seeing. It’s a constant learning process.”
Dr. Creamer agrees. He used to veer from his day-to-day routine and “follow around Max Kutzer, an internist at Crouse Hospital here at Syracuse, who practiced for years and who taught the physical exam to medical students at Harvard in 1954,” a time—he points out—when little-to-no diagnostic technology existed. Accompanying this master of medical observation, he says, was a Zen-like experience. The elder doctor “would walk to a patient’s doorway and stand there and watch the person breathe and watch how disheveled the bed was, whether the chair had been sat in, and [after] a couple of minutes he would walk out and say, ‘Now tell me what you noticed.’ ”
Dr. Creamer remembers naming “two or three things. But [Dr. Kutzer] would say, ‘OK, but let me tell you 10 more.’ ” Dr. Kutzer, now 96 and still productive, Dr. Creamer says, has written a book, Observation and the Physical Exam, which is in the editing stage.
Because physicians are pressed for time, those powers of observation may be, if not lost, at least largely neglected or ignored. “But I still do those things,” says Dr. Creamer. “I’ll walk to the door and watch a person breathe while they’re sleeping … . You lose the anxiety overtones when you’re watching someone sleeping. … In order to learn, you need to listen. Listening takes time. You’ve got to step back and take the time to learn, and that’s where it gets tricky.”
Dr. Bomback believes technology will never replace the power of observation. “Those are the unique skills that come with being a hospitalist or any physician … and a lot of the reason why most people become physicians,” he says. “It is a skill that [they have had] from early on. It’s empathy, that you can observe a patient and understand what’s going on—maybe not completely, and not totally consciously, but there is an empathic sensation.”
Conclusion
The traditional use of the physical exam may have changed, but its value is still important to patient care.
“The physical exam is part of the culture of medicine,” says Dr. Jauhar. “It may have started to lose some of its utility as we get more technology, but it can limit the use of technology and help us make diagnoses more quickly.”
Providers might also sometimes be in a place “where you don’t have a CT scan or an MRI machine,” he adds. The provider discovers things that machines can’t supply, and the contributions of even a brief physical exam can communicate humanity to the patient.
“I have always wondered how physicians can do telemedicine,” says Dr. Dickey, “because there is something about being there and being with the patient in terms of judging the severity of illness that is very important.”