The Doctor’s Advocate | Second Quarter 2019
An Ounce of Prevention
The Waning of the Physical Examination and Its Impact on Outcomes
The physical examination (PE) has always been an integral part of medical practice. In the 18th century, Josef Leopold Auenbrugger, an Austrian physician, observed his father tapping wine barrels in the cellar of his hotel to determine how much wine was left. Subsequently, the son applied this method to patients, thus introducing the technique of percussion to the practice of medicine.
René Théophile Hyacinthe Laënnec, a French physician, famously invented the stethoscope in 1816 and pioneered its use in diagnosing various chest conditions. It remains of central importance in detecting useful information, including heart valve problems, heart failure, heart rhythm problems, partially occluded blood vessels, pneumonia, asthma, and emphysema.
Sir William Osler, an esteemed Canadian clinician of the late 19th and early 20th centuries, promoted the rituals of inspection, palpation, percussion, and auscultation into the mainstream of clinical practice.
A recent study discussed the clinical implications of an inadequate PE as a cause of medical error and adverse events. In a collection of 208 vignettes, PE oversights led to missed or delayed diagnoses, unnecessary exposure to contrast and radiation, incorrect treatment, and other adverse consequences. Specifically, 63 percent of oversights were caused by failure to perform the PE, 14 percent reported that the correct PE sign was elicited but misinterpreted, and 11 percent reported that the relevant sign was missed or not sought.
A 19-year-old obese female one month postpartum presented with a chief complaint of right-sided anterior lower chest pain located below the breast. The pain had begun after an uneventful delivery and had persisted for one month. She had no prior history of similar symptoms. During this period, the patient had been evaluated on four separate occasions in two different emergency rooms—including on the day prior to the current office visit. She had been told that her EKG and chest x-ray were normal, and she was prescribed albuterol for asthma. On examination in the office, her vital signs and chest and heart examinations were normal. On abdominal examination, however, the patient had significant tenderness and some guarding to deep palpation in the right upper quadrant. She indicated that no one had previously examined her abdomen. Lab studies showed an increase in transaminase and alkaline phosphatase, and the abdominal ultrasound showed multiple gallstones. The ultrasound technician also reported a positive Murphy’s sign* resulting from transducer pressure on the abdomen. She was diagnosed with symptomatic cholelithiasis and underwent a cholecystectomy with resolution of symptoms.
In addition to aiding predictive value in diagnosis and treatment, an accurate PE may result in substantial cost savings. Evidence indicates that physicians (including gastroenterologists) may be reluctant to perform a digital rectal examination (DRE) despite the presence of GI symptoms. Studies report a DRE lacking in 10 to 35 percent of patients with acute GI bleeding. However, performing a DRE decreases the frequency of hospital admissions because it helps to characterize findings of gross blood, stool mixed with blood, trace blood, melena, guaiac-negative black stool (bismuth), and guaiac-negative red stool (beets)—which can improve management decisions. It is important to remember that, for some diseases, the PE is the only diagnostic tool available. Examples include Parkinson’s disease, herpes zoster, cellulitis, and Bell’s palsy.
There are multiple explanations for the erosion of the PE:
- Hospital graduate medical trainees spend as little as 12 percent of their time in direct contact with patients and their families and as much as 50 percent of their time on the computer.
- In an age of technology, medical trainees may fail to recognize the value and relevance of the PE and fail to see that some PE maneuvers are as reliable as technology-based tests.
- The PE is often taught as a long list of maneuvers to be performed regardless of the clinical context. This rote misutilization of the one-size-fits-all PE undermines the value of the focused examination or even of highly specialized maneuvers, such as Murphy’s sign.
Some medical schools lack emphasis on training in physical diagnosis. In a study of 106 medical schools, half of the schools allotted less than 15 percent for practice time with patients. This resulted in a median of 15 hours of training with a real patient. In another study of final-year medical students, the median number of rectal examinations performed during medical school was two, with 17 percent of students performing none. In still another study, 42 percent of final-year medical students had performed fewer than five rectal examinations.
The impact of the electronic health record (EHR) on the performance and documentation of the bedside PE is mixed. PE templates have emerged as a tool, but common pitfalls have also emerged. These include the following:
- Clinicians are more likely to document their findings after considerable time has elapsed from the actual examination—which affects accurate recall.
- Templated phrases corresponding to portions of an examination may not have been performed—which results in inaccurate documentation.
- Copy-and-paste functions allow prior recorded findings to substitute for a current examination—which contributes to diagnostic bias and potentially constitutes fraudulent documentation.
- While paper notes are more likely to suffer omissions (41 percent versus 17 percent), the EHR is more likely to suffer inaccuracies (24 percent versus 5 percent).
In addition to the value of the PE in improving diagnostic accuracy, the “laying on of hands” is an honored ritual of caring and healing that makes our profession truly unique. The value of the PE in building and maintaining the physician-patient relationship is important. Patients’ complaints about physicians often include “The doctor never touched me” or “The doctor never laid a hand on me.” The privilege of touch is given to few other professions in society. This ritual of caring and healing involves unique characteristics:
- It occurs in a specific, symbolic setting.
- It involves symbolic tools, e.g., a stethoscope or reflex hammer.
- It emphasizes the actual patient as the center of attention (rather than a digital or scanned image).
- It provides an opportunity to create a bond between the patient and doctor.
- For the physician, patient contact supports the opportunity to form a meaningful relationship and a respite from data entry.
Skills in performing the PE are waning for many reasons. Despite declining skills, many of the PE diagnostic tools developed over the years continue to have value, and, combined with 21st-century technology, they guide the clinician toward rapid and accurate diagnosis.
The PE is far from dead and should remain a central tool for evaluating and managing patients. For additional information about improving diagnostic skills, we recommend the Stanford Medicine 25 website (https://stanfordmedicine25.stanford.edu/the25.html), which includes detailed descriptions of both common and unusual PE techniques.
*Murphy’s sign: Named after American physician John Benjamin Murphy (1857–1916), a prominent Chicago surgeon from the 1880s through the early 1900s, who first described the hypersensitivity to deep palpation in the subcostal area when a patient with gallbladder disease takes a deep breath.
Costanzo C, Verghese A. The physical examination as ritual: social sciences and embodiment in the context of the physical examination. Med Clin North Am. 2018 May;102(3):425-431.
Garibaldi BT, Olson APJ. The hypothesis-driven physical examination. Med Clin North Am. 2018 May;102(3):433-442.
Hedian HF, Greene JA, Niessen TM. The electronic health record and the clinical examination. Med Clin North Am. 2018 May;102(3):475-483.
Johnson DA. Value of the lost art of a good history and physical exam. Clin Transl Gastroenterol. 2016;7(1):e136.
Shrestha MP, Borgstrom M, Trowers E. Digital rectal examination reduces hospital admissions, endoscopies, and medical therapy in patients with acute gastrointestinal bleeding. Am J Med. 2017 Jul;130(7).
Uchida T, Achike FI, Blood AD, et al. Resources used to teach the physical exam to preclerkship medical students: results of national survey. Acad Med. 2018 May;93(5):736-741.
Verghese A, Charlton B, Kassirer JP, Ramsey M, Ioannidis JP. Inadequacies of physical examination as a cause of medical errors and adverse events: a collection of vignettes. Am J Med. 2015 Dec;128(12).
Zaman JAB. The enduring value of the physical examination. Med Clin North Am. 2018 May;102(3):417-423.
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