Dr. Verghese, above, gives us a fun and seemingly unobjectionable TED talk calling for the revival of the physical exam -- one that unfortunately illustrates why the physical exam is dying of neglect.The TED audience seemed to like it, but I feel like I have heard this lecture with slight variations every year since the start of med school.
Doing medicine from behind a computer is condemned. Traditional rounds with extensive histories and physical exams are praised. The glorious history of the physical exam is recounted. Said history always includes allusions to Arthur Conan Doyle and Auenbrugger tapping wine barrels, Laennec watching children play, and so on.
While they touch on the diagnoses missed and patients harmed by hasty or sloppy exams, the lion's share of the talk is always devoted to how the exam makes the patient feel -- how it helps or harms the patient's emotional connection with their doctor, how the exam reassures, how it conveys the unironically invoked "healing touch."
None of this is wrong, but it damns the exam with faint praise. It skirts past and implicitly concedes the question of what actual, reliable, actionable information can be obtained by the physical exam. How good is the physical exam at achieving its declared goal of giving us useful information about illness?
The problem of time is also intertwined with this, and also is ignored by Dr. Verghese, who speaks rapturously of splitting an exam off into its own half-hour appointment so that he can discuss the history uninterrupted during the first half-hour appointment. How does this anecdote help me in the emergency room, in the ICU, or on the wards? Fuck you very much, Dr. Verghese.
But it's not really his fault; he's just carrying on a proud tradition of unreality surrounding medicine at the bedside. How many prescribed work-ups open with this infamous phrase: "Do a complete history and physical exam." Anybody do that? Or anyone? Ever?
And that's the problem with those teaching rounds, too. So you want the hospitalist attending, with 20 people on their service, to interview and examine every patient, every day, with Q-and-A with the residents at bedside?
If you really want to promote the physical exam, the way to do so is exactly the opposite of Dr. Verghese's method. Enough about the exam's noble history. Bleeding has a noble history in medicine, too, but that didn't save it from the dustbin. The physical exam will rise or fall based on its clinical utility, which is determined by:
1. The sensitivity and specificity of particular maneuvers for particular conditions (see the Rational Clinical Exam series or Physical Diagnosis Secrets for examples of this research). Stuff that is not sensitive or specific needs to go (bowel sounds, I'm looking at you). There are 1440 minutes in every day and God's not making any more time.
2. To make this research applicable to the bedside, we need to agree on a standardized technique for performing a given maneuver. Students need to be taught a consistent method; students and residents need to be regularly supervised and evaluated in their performance of the exam.
3. Students should learn how to do a comprehensive exam, but textbooks and instructors need to acknowledge the reality of limited time and state explicitly what parts of a comprehensive exam can be safely omitted in which patients. Do you need a heart and lung exam in a healthy 20-year-old with a sprained wrist and no other complaints? Obviously not, but common sense is often ignored in the teaching of the physical exam.
If I were to sum up my program here in a single sentence, I would say: To restore the respect for the physical exam vis-a-via tests and scans, we must apply all the same principles that guide our use of tests and scans:
1. What we do should be evidence-based.
2. We shouldn't be indiscriminate or unfocused in our application of these tools. Our time is as precious a resource as the time of the MRI scanner.
3. We should use sensitivity and specificity to guide our use of these tools in making a diagnosis. Some will rule in, some will rule out, some will be used in parallel, some in series.
4. How we do a test/scan/exam may vary from place to place, but it should be, as far as possible, standardized around best practices, so we know the research we are using applies, and we can trust the results reported to us from elsewhere.
There is no question that the act of touching the patient deepens our relationship with them, and has an intangible value. That is a given. But it is also, if performed properly, a ruthlessly effective way to gather critical information about multiple systems simultaneously without exposure to radiation or expensive and time-consuming blood tests. The exam is fully capable of justifying itself within the paradigm of scientific medicine, and can be optimized for that task without losing any of its -- literal -- touchy-feely bona fides. What we must not do is strive to preserve an idealized and historically driven vision of the physical exam, which will lead to an impractical mess -- heartily praised and rarely performed -- that it is not subject to investigation and systematic improvement because it is justified in the first place as relationship-building, as emotional or spiritual comfort, a performance rather than an investigation.
The physical exam is not the ground on which to fight a battle over medicine as art versus medicine as science. The physical exam -- the act of looking, listening, feeling, and make decisions on the basis of the empirical evidence gathered -- belongs wholly to science. Appealing to art, like appealing to the notion of emotional and spiritual comfort, is not factually wrong, but is an act of self-defeating desperation.
The exam needs to be continually tested and improved by scientific investigation and critical judgement, or it will fall hopelessly behind blood tests and scans, where such continuous improvement is routine. Loving the physical exam, as I do, means not fearing for its fate at the hands of evidence-based medicine. It is a powerful and practical tool, and we can continue to prove that as we continue to improve it.