I recall the moment I fully grasped the critical importance of the physical exam and how easily it can be overlooked, often with serious consequences.
Early in my fellowship, an elderly patient was referred to our team with an apparently straightforward case of sciatica. His MRI revealed a disc herniation at L5/S1 with foraminal narrowing, prompting discussion about whether an epidural injection or surgery would be more beneficial. I was tasked with performing an electrodiagnostic study as part of the evaluation.
When the patient changed into a gown, the true cause of his pain became immediately apparent: an inflamed shingles rash extending along the path of his sciatic nerve. Neither surgery nor an epidural would have been beneficial; indeed, both could have caused unnecessary harm. The diagnosis was unmistakable but detectable only through direct observation.
That moment remained with me. It did not reflect a failure of intelligence or dedication on the part of the clinicians who had previously evaluated him. Rather, it exemplified a broader trend in modern medicine: the gradual erosion of trust in clinicians’ own senses, overshadowed by the increasing reliance on sophisticated diagnostic technologies.
A lesson learned as a patient
Years later, I experienced this lesson firsthand as a patient.
In the summer of 2025, I was diagnosed with prostate cancer. Although my care team was skilled and well-intentioned, I quickly recognized how easily critical information can be overlooked when the physical exam is neglected.
One week post-surgery, I developed severe, non-radiating back pain that rapidly worsened to near incapacitation. Upon presenting to the emergency department, the physician reviewed prior spinal imaging and attributed the pain to a pre-existing disc condition. No physical examination was performed.
Several hours later, the pain intensified and did not respond to potent opioids previously unused by me. A pelvic CT scan was ordered, revealing one liter of postoperative fluid accumulation. After the interventional radiology team arrived and drained the fluid, relief was immediate and complete. This complication was overt and could have been detected by a simple physical examination, thereby expediting appropriate diagnostic testing and treatment.
These experiences, initially as a trainee and later as a patient, shaped my understanding of the enduring value of the physical exam. They also convey an important message for future clinicians.
Why the physical exam still matters
Despite remarkable advances in diagnostic technology, the physical exam remains one of medicine’s most powerful tools. It provides several key advantages:
- Cost-free
- Non-invasive
- Immediately available
- Capable of detecting a wide range of abnormalities that imaging may miss or misinterpret
Our senses, sight, touch, and hearing, are the product of millions of years of evolution. They are finely attuned to detect subtle changes in temperature, texture, symmetry, and movement. No imaging technology can match the breadth of information a skilled clinician can gather within minutes at the bedside.
But physical exam skills do not come automatically. They require deliberate practice. Without regular use, they fade. Without structured reinforcement, they slip to the edges of clinical reasoning. Trainees can strengthen their exam skills by practicing exams with peers, using checklists to ensure all key elements are covered, and regularly seeking feedback from supervisors and colleagues. Taking a few minutes after each patient encounter to reflect on what was found or missed can further sharpen these abilities. Turning the physical exam into a consistent habit, rather than an afterthought, makes it far more likely to yield its full value at the bedside.
Re-centering the physical exam in medical training
To maintain the physical exam as central to diagnosis, medical education must adopt the following approaches:
- Dedicated, ongoing skills training: Physical examination instruction should not be confined to the early years. Skills laboratories, bedside rounds, and simulation sessions must continue throughout residency, accompanied by clear feedback from experienced clinicians.
- Routine integration into clinical workflow: Residents and students should be both encouraged and expected to perform focused examinations prior to ordering diagnostic tests. This practice reinforces the physical exam as the foundation of diagnostic reasoning rather than an optional component.
- Faculty role modeling: When attending physicians demonstrate careful and thorough examinations, trainees internalize their value. Conversely, when attendings omit exams, trainees perceive such omissions as acceptable.
- Reflection on diagnostic errors: Case discussions that emphasize missed findings or excessive reliance on imaging help learners appreciate the physical exam’s practical significance.
A call to the next generation
The objective is not to diminish the value of imaging or laboratory tests, which are indispensable. However, these tools are most effective when employed to address questions that persist following a thorough history and physical examination, rather than as substitutes for them.
As you progress through training, remember that your senses are not outdated relics from a pre-technology era. They are sophisticated instruments capable of detecting patterns and abnormalities that no machine can fully replicate.
The physical exam is not merely tradition; it constitutes a discipline, a craft, and a cornerstone of safe, effective, and compassionate care.
By maintaining the physical exam at the center of your practice, you honor both the science of medicine and the humanity of the patients who place their trust in you.
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.
Dr. Torres was born in Spain and grew up in Puerto Rico. He graduated from the University of Puerto Rico School of Medicine. Dr. Torres performed his physical medicine and rehabilitation residency at the Veterans Administration Hospital in San Juan before completing a musculoskeletal fellowship at Louisiana State University Medical Center in New Orleans. He served three years as a clinical instructor of medicine and assistant professor at LSU before joining Florida Spine Institute in Clearwater, Florida, where he is the medical director of the Wellness Program.
Dr. 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. He is a prolific writer and primarily interested in preventative medicine. He works with all of his patients to promote overall wellness.
