As a pain management specialist, I have often found that the course of treatment for a patient requires a careful balance of many factors before making a recommendation. But sometimes, the best course seems obvious. That was the case with Mr. Bautista (name replaced to protect identity). He was an older gentleman, and his imaging scans showed spinal stenosis that was likely to lead to nerve pain. And what was his chief complaint on that day? Excruciating pain in his lower back, of course.
It would have been easy to prescribe him a standard battery of physical therapy or pain medication. However, the actual cause of Mr. Bautista’s back pain was not as straightforward as it seemed. His pain did not stem from his spinal stenosis or any musculoskeletal issue. It was only through a thorough physical exam, with particular attention to the lower back, that I discovered the presence of an easily recognizable rash. My patient had shingles, which would have gone undetected if not for having opted to do a thorough examination beyond the apparent obvious. This example underscores the critical role of the physical exam in accurate diagnosis and effective patient care, enlightening us about its importance.
In medical school, Hoppenfeld’s book on physical examination was our Bible. We learned that the patient’s history and physical examination were the two most essential steps before ordering imaging or lab work. How could we even know what to test for if we had not physically examined the patient to determine if there were any signs of injury, infection, or dysfunction evident in their bodies?
Surprisingly, in recent years, there has been a significant lack of training in conducting formal physical examinations among medical students and graduates. Many do not consider this a fundamental and essential thing to do. Often, those asked report that they would proceed with the diagnosis and treatment of a patient without relying on the physical examination. This is not only ill-advised but also counterintuitive. It could be said that modern imaging and laboratory tests have become so good that they have made physical exam results for diagnostic purposes unnecessary. But this hypothesis has proven to be baseless. As a senior doctor, I know from experience that patients’ imaging results often only loosely correlate to their symptoms and that fatal illnesses can be missed, even with the best imaging scans.
I have found support for this view in the medical literature. For instance, in a 2021 article published by the Journal of Family Medicine and Primary Care, Drs. Rachna and Yogesh Jain examined why many of their rural medical patients report never having received a physical exam from previous doctors. They were trying to determine whether there is any basis for the idea that physical exams are less valuable today than thirty years ago.
This decline in physical exams in recent years could be traced back to an unexpected source: the COVID-19 pandemic. During this time, doctors were encouraged to socially distance themselves from non-critical patients, leading to a shift in care habits towards using mechanical means of diagnosis that could be performed without close physical contact with potential COVID carriers. This two-year social distancing has led to a permanent cultural shift, at least as I observe in my area of practice, where newer doctors do not view physical exams as a routine part of patient care. However, as we move past the pandemic, it is crucial to re-emphasize the value of physical exams in patient care and ensure that this essential practice is not overlooked in the future.
Drs. Rachna and Jain asked the same question I did. Namely, is there any reason to think physical exams are less necessary now than thirty years ago? I believe that the answer should be a resounding “no.” Research indicates that insufficient physical examination is the number one most common cause of diagnostic and treatment errors. This finding should instill a sense of hope and optimism in the medical community, as it underscores the potential of physical exams to significantly reduce medical errors, giving us hope for a more accurate and effective health care system.
Drs. Rachna and Jain cite a 2015 study by Ioannidis et al. that studied the causes of 208 adverse events, including missed or delayed diagnosis, unnecessary exposure to imaging radiation, incorrect patient treatment, and other adverse outcomes.
In their work, Ioannidis and their co-authors found that 63 percent of the errors in their data set were caused by doctors failing to examine the patient physically. Still, diagnostic or treatment errors did occur in another 25 percent of cases where a physical exam was performed. However, many involved physicians need to execute proper specific examination maneuvers or simply misinterpret their exam results. This suggests that the lack of any physical exam, sufficient skill, and thoroughness during physical examinations played a role in 88 percent of medical errors studied. These errors can lead to adverse patient outcomes, unnecessary costs for the health care system, and a loss of trust in the medical profession.
Given rising health care costs and the significant operational challenges they pose to health care systems, there is a strong case for a return to more routine physical examinations and the development of required skills. This could be one of the most promising interventions to cut costs while improving patient outcomes. Further, this should be a powerful motivator for all medical professionals to commit to thorough physical examinations, instilling a sense of commitment and motivation in our practice.
In spite of these strong indicators of potential benefits, many patients report not receiving a physical exam from a doctor in recent years, and many doctors report that physical exams are not a routine part of their patient evaluation practice.
I am reminded of a senior surgeon I knew in the 1990s. Even then, he had developed a somewhat arrogant attitude. He would review a patient’s X-rays before agreeing to see them and refuse to treat patients if their X-rays did not suggest that they warranted his attention.
It seems that even thirty years ago, doctors were tempted to think that the results of imaging or lab tests were more “objective” than patient reports of symptoms or that these technology aids could give more valuable information about patients’ health states than our own eyes and hands.
However, research shows that this is a false premise. Attempts to substitute imaging and lab tests for physical exams only result in medical errors and rising cost burdens for our health systems.
Fortunately, there are signs of change. Some health systems have recognized the problem and are taking steps to improve physical exam education for doctors and medical students. A study by Ogino et al. is a testament to this. Introducing physical exam training as one of the first topics in the medical school curriculum and testing students’ physical exam proficiency using an “escape room” model significantly enhanced students’ motivation and confidence in performing physical exams. This shows we can improve physical exam education in medical training with the right approach.
After receiving physical exam training throughout each year of medical school and graduating from “escape room” trials, virtually all students reported enhanced motivation to learn and conduct physical exams, and 89 percent completed the “escape room” tests successfully. Medical students’ average confidence in performing physical exams rose from 49 out of 100 before introducing “escape room” scenarios to 73 out of 100 after completing the escape room course.
This is one arena where we must return to basics as a medical community. A high percentage of medical errors are preventable with adequate physical examination, and physical exams also hold tremendous potential for cost-cutting and reducing financial burdens on health care systems. This understanding should empower every medical professional to take responsibility for their practice and commit to thorough physical examinations.
While my teachers taught me to approach the art of the physical exam as a care-based and humanizing interaction, methods such as introducing physical exam education earlier and using “gamification” methods to motivate medical students and improve their confidence also hold promise for addressing a possible rise in the loss of physical exam adequacy in medical culture around the world during the COVID-19 pandemic.
Francisco M. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine and can be reached at Florida Spine Institute and Wellness.
