I intended to write an essay endorsing the clinical examination (CE), but recent personal events have made me reconsider. I had outpatient sinus surgery and developed chest pain the next day, leading me to my local rural hospital’s emergency department (ED). The ED physician diagnosed atrial fibrillation, and a CT scan revealed a small pulmonary embolus. I was then transferred to a city hospital and eventually cardioverted to sinus rhythm.
Despite receiving appropriate treatment, I question the use of CE in modern medicine. The health care providers who attended me received varying scores for their CE skills: the first ED doctor limited her examination to cardiac auscultation and wrist pulse, the second ED doctor did not examine me, the ICU nurse practitioner and cardiologist did not examine me, and my ENT surgeon did not examine me due to the anticoagulant. The hospitalist only saw me after I threatened to self-discharge, but even then, he did not examine me. No one examined me for deep vein thrombosis (DVT).
The Institute of Medicine’s 2015 publication “Improving diagnosis in health care” defines diagnostic error as “the failure to establish an accurate and timely explanation of the patient’s health problem and communicate that explanation to the patient.” Despite technological advances, misdiagnosis remains rampant and has not improved in the last 20 years. A 1996 study in Medicine found that the patient’s history and physical examination led to a correct diagnosis in 60 to 70 percent of cases, and a 2015 paper in the American Journal of Medicine concluded that inadequate physical exams led to missed or delayed diagnoses, incorrect diagnoses, unnecessary treatments, and unnecessary exposure to radiation or contrast.
Medical students should be taught how to perform a rapid, focused CE that yields maximum information and when not to perform a CE. The Stanford 25 teaches precision bedside examination, and Sapira’s Art and Science of Bedside Diagnosis and the JAMA series “The rational clinical examination” provide real-world examples of the role of CE in patient care. The physical contact alone is of great value to the patient, even if the CE does not reveal anything significant for diagnosis or management. In conclusion, despite my recent experience, I still believe there is a role for CE in today’s medicine.
Martin C. Young is a pediatric endocrinologist.
