How important is a doctor’s skill in the physical examination of a patient?

To the lay person, a doctor’s examination might seem really important.  “Of course it is, Dr M … Come on.”

But is it so?  Or, perhaps, is the examination a charade, a show, a necessity to complete the medical record.

It turns out that many in the profession think doctors may be losing the skill of palpating and listening.  At least NPR said so recently, in their piece on the fading art of the doctor’s exam.

Does a mastery of physical exam skills really help us to be better doctors?  What’s the real impact factor of the physical exam?

Such is a tug-of-war, where the older generation (let’s call them seasoned physicians) who think they can palpate gallbladders, pull against the new generation of doctors who are equipped with ultrasound skills and i-stat lab machines which can (in minutes) determine the patient’s left atrial pressure or hemoglobin concentration. Is the redness of the conjunctiva (lining of skin inside the eye) really that important when one can quickly know the hemoglobin concentration with a pin-prick of blood?

But surely there must be an intangible effect of the doctor who expertly and compassionately palpates, observes and listens to the body’s whispers. I have felt this myself, when I was a patient.

The stethoscope felt cold on my back. He was going through the motions of the exam; I knew this and he knew that I knew. The problem at hand was geographically distant from my heart, but I knew that listening to my heart valves click open and closed was necessary to complete the consult.  As in this day and age, for a consult to be compensated, enough bullet points have to be noted. I wasn’t paying him to exam my heart. When he started listening to my heart, I thought, “you know, I am a cardiologist.”

But then, during the exam, a funny feeling came over me.  It was a comforting sensation, like I was being checked over with thoroughness, and care. I knew there was nothing wrong with my heart or lungs, but the hands and attention felt right. It was both intangible and real at the same time. “He’s a good doctor,” was the sensation I felt.

In the real world though, we only have a precious few moments to take a history, do an exam and explain the many possible treatment options.  If care is “patient-centered” we have already spent much time listening to the patient’s problem, their perception of the problem and any associated socio-economic contributing factors to their problem.  That’s a lot to do in our allotted time — especially if the patient is an engineer.  Do patient’s want the intangible of the doctor’s touch, or a detailed explanation of the treatment options?  Oh, and I almost forgot the increased time it takes to fill out the 4-page medical record, which used to be just a minute or two to dictate a personal letter to the referring doctor, but now is something so electronic, so sterile, so awful.

Take as an example, the bedside evaluation of atrial fibrillation (AF). (But for the sake of argument, you could substitute a myriad of other diagnoses, like cancer, diabetes or obesity.) You have reviewed the patient’s records. There is an ECG that shows AF, or a biopsy that shows cancer, or a blood sugar that shows diabetes.  The diagnosis is certain and the patient needs something done more than just a nice physical exam. In AF for example, you know they will need an echo, not for cover-your-butt purposes, but rather for real-life treatment decisions, like in good medicine.  When an echocardiogram is done, or to be done, the auscultation of the heart tones seems eight parts pomp and two parts circumstance.

The NPR story singled out echocardiograms as an example of “expensive” tests that doctors order indiscriminately. It was a horrible example. Healthcare costs are not spiraling upward because of too many echos. To treat AF correctly, a non-invasive, painless and really not-that-expensive ultrasound is appropriate. Plus, as DrRich points out, echocardiograms really don’t have to be as costly as they are. (But that’s another really long post in and of itself.)

Back to the patient-centered model.  The patient-encounter time clock is ticking. There isn’t a lot of time to play around with gait analysis, eye-exams and tuning forks.  Doctors who are masters of the obvious know this.

So, how much laying on of hands is needed for good doctoring?

It varies, as it always does in the real, un-electronic world.  Like when the nurse-practitioner comes out of the room frazzled, and tells me to put on the white coat before I go in.  This patient may need more exam.  Or, you may need more physical exam when you are in the rural clinic without an ultrasound machine or nuclear camera.  Wait, that’s a bad example; even rural clinics have these technologies now.

The real story is that in pure objectiveness of findings the physical exam is eclipsed by modern technology, by a bunch.

But in forging a trusting relationship with the patient the examination still holds great value.

Just don’t waste too much time with the tuning fork.

And get everything documented, even those pale conjunctiva.

John Mandrola is a cardiologist who blogs at Dr John M.

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