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Final Exam?


 

You enter a patient’s room with all your senses on alert. You absorb the environment quickly—even before addressing the patient. It is perhaps these “small moments in medicine,” the under-the-radar information, that a physician may best remember about individual people or cases, says Andrew Bomback, MD, a first-year fellow in nephrology at the University of North Carolina at Chapel Hill. “Not the details of a specific disease state,” he elaborates, “but the visceral memory, such as how someone smells.”

In his article, “The Physical Exam and the Sense of Smell,” published in the New England Journal of Medicine in January 2006, Dr. Bomback writes that his training by doctors who “preached the gospel of the physical exam” was intended so that he and his fellow students “would not forget that the best doctors help their patients with their eyes, ears, and hands, not just with numbers posted on a computer screen.”1

Those small moments are often usurped from doctors as they deal with the demands and obligations of their jobs in an often-hurried environment. Let’s face it, he says, “The physical exam has just been truncated to very brief encounters.”

In fact, facing this dilemma is one of the first remedies he would prescribe. In response to the article, “I got a lot of nice letters from [physicians] who related similar incidents that happened in their training, where they used smell to learn more about a patient,” he says.

In contrast, he also received “somewhat negative letters where the message from those mostly retired physicians was, ‘You’re just not spending enough time with patients.’ I think that is a very unrealistic piece of advice,” says Dr. Bomback. “It would be very interesting to see whether they could carry the pager of a hospitalist or resident for 12 hours and actually be able to do what that hospitalist or resident does.”

Physicians today must first acknowledge the reality “that we don’t have as much time as we need,” says Dr. Bomback. “And once you admit that you’re not going to be able to spend as much time as you ideally would like … that we only have a 12-hour work shift if you are a hospitalist or a 30-hour call shift if you are a resident,” you have to maximize the time with the patient by giving “a focused physical that it is well done, accurate, and respectful to the patient.”

In order to learn, you need to listen. Listening takes time. You’ve got to step back and take the time to learn, and that’s where it gets tricky.

—Tim Creamer, MD, director, hospital medicine program, Community General Hospital, Syracuse, NY

Crisis or Evolution?

Sandeep Jauhar, MD, director of the Heart Failure Program at Long Island Jewish Medical Center, New Hyde Park, N.Y., also had an article in last year’s NEJM “Perspective” series.1-4 In that piece, “The Demise of the Physical Exam,”2 Dr. Jauhar posed a question: Is the demise of physical diagnosis a crisis or a natural evolution? Now, a year later, The Hospitalist asked him that same question.

“I don’t view it as a crisis,” he says, “but maybe that’s because of my vantage point as a cardiologist. Cardiology is very technology-driven; very few diagnoses are made on the basis of the physical exam.”

Dr. Jauhar believes that the greatest benefit of performing a thorough physical exam is not necessarily to pin down a diagnosis, though it can expedite that process, but to limit the tests that are ordered.

William Dickey, MD, hospitalist and director of quality at Abbott Northwestern Medical Center, Minneapolis, Minn., agrees that the decision of what testing to do, if any, is still guided by the physical exam.

“The high-tech diagnostic testing doesn’t demean the importance of the exam of all,” he says, but its role may have changed.

Are the intricate skills of performing a physical exam imperative, or have they mostly been replaced by technology? “I would say they’re not fully imperative under the assumption that you have the technology and you want to get the job done,” says Dr. Bomback. “Are they desired? Absolutely. A good physical exam and a remarkable finding are about showing what goes on inside the body and manifests itself outside the body.”

The ability to adequately hear a heart murmur or detect tetany is based on the physiologic understanding of why that murmur occurs or how calcium metabolism works. With that in mind, Dr. Bomback believes all patients would want their doctors to have those skills. “But,” he quickly qualifies, “could you have a functioning doctor get through his or her workday without knowing that? Absolutely. Could a cardiologist treat CHF without being able to hear a murmur? Of course. … So it’s desirable, but it’s not totally necessary.”

One reason for the desirability of maintaining those skills, which require physicians to “get up close,” as Dr. Dickey puts it, pertains to the importance of touching, seeing, and listening and to the quality of the patient-physician interaction itself.4 All the physicians interviewed for this article concur that getting that physical sense of the patient will tell you things that other information will not, and involving this true sensitivity in the interaction will most likely put the patient at greater ease.

“Because, in addition to all the information that a physician can discover from doing a physical exam, there is also a sense of rapport that the physical exam builds,” says C. Martin Buchanan, MD, FACP, a hospitalist at Penrose Hospital in Colorado Springs, Colo. “The therapy of being there, being present at the patient’s side, touching the patient, doing something for them, having a kind of healing energy, if you will, that we … transmit to the patient and [which essentially communicates], ‘I’m here to help you, I accept you as a human being even though you’re ill; I’m willing to touch you, and I’m here to help you feel better.’”

Not a Demise, but Compromised

“The physical exam is compromised during patient assessment because of where it ranks in importance,” says Tim Creamer, MD, director of the hospital medicine program at Community General Hospital in Syracuse, N.Y. “There are people who say that history is 80% of the diagnosis, which makes the physical exam 20% of the diagnosis. Although you try to emphasize that diagnostics, such as X-rays and labs, should only confirm your history and physical, we still depend too much on the technology to diagnose for us.”

The physical exam is not emphasized after medical school, says Dr. Creamer, who teaches second-year family practice residents. The emphasis now has become the patient-doctor interface: educating and talking with the patient and family. “And even in the lay literature, they encourage consumers to ‘Get your doctor to spend time with you,’” he says. “They mean talking to you, not checking your neck veins for A, C, and V waves.” Hospitalists may also minimize the physical exam, he adds, “because we feel pressured to maximize the talking and listening.”

The Focused Physical

The newest title in the 2006 edition of the Medical Knowledge Self-Assessment Program (MKSAP), published by the American College of Physicians, “Foundations of Internal Medicine,” includes an extensive discussion about the evidence-based physical exam. A good deal of recent research has addressed the topic of which physical findings are truly important to assess various conditions.

“If internists will pay attention to what’s in the medical literature about reliable physical findings,” says Dr. Buchanan, “we can tailor our physical exam a bit better, make more efficient use of the [interview] time, and provide very useful information for our diagnostic assessment and treatment planning.”

The MKSAP-14 offers 11 print books, a CD-ROM, and a new online version. Information is available at www.acponline.org/catalog/mksap/14/.

Powers of Observation

Performing a good physical exam is “something that we all aspire to and something we always try to improve,” says Dr. Bomback. “Anytime I hear of someone with a good physical exam finding I will try to see that patient.” It’s one of the reasons he likes working in an academic center. “There are always interesting cases, and there is always someone who wants to teach someone else what they’re seeing. It’s a constant learning process.”

Dr. Creamer agrees. He used to veer from his day-to-day routine and “follow around Max Kutzer, an internist at Crouse Hospital here at Syracuse, who practiced for years and who taught the physical exam to medical students at Harvard in 1954,” a time—he points out—when little-to-no diagnostic technology existed. Accompanying this master of medical observation, he says, was a Zen-like experience. The elder doctor “would walk to a patient’s doorway and stand there and watch the person breathe and watch how disheveled the bed was, whether the chair had been sat in, and [after] a couple of minutes he would walk out and say, ‘Now tell me what you noticed.’ ”

Dr. Creamer remembers naming “two or three things. But [Dr. Kutzer] would say, ‘OK, but let me tell you 10 more.’ ” Dr. Kutzer, now 96 and still productive, Dr. Creamer says, has written a book, Observation and the Physical Exam, which is in the editing stage.

Because physicians are pressed for time, those powers of observation may be, if not lost, at least largely neglected or ignored. “But I still do those things,” says Dr. Creamer. “I’ll walk to the door and watch a person breathe while they’re sleeping … . You lose the anxiety overtones when you’re watching someone sleeping. ... In order to learn, you need to listen. Listening takes time. You’ve got to step back and take the time to learn, and that’s where it gets tricky.”

Dr. Bomback believes technology will never replace the power of observation. “Those are the unique skills that come with being a hospitalist or any physician … and a lot of the reason why most people become physicians,” he says. “It is a skill that [they have had] from early on. It’s empathy, that you can observe a patient and understand what’s going on—maybe not completely, and not totally consciously, but there is an empathic sensation.”

Conclusion

The traditional use of the physical exam may have changed, but its value is still important to patient care.

“The physical exam is part of the culture of medicine,” says Dr. Jauhar. “It may have started to lose some of its utility as we get more technology, but it can limit the use of technology and help us make diagnoses more quickly.”

Providers might also sometimes be in a place “where you don’t have a CT scan or an MRI machine,” he adds. The provider discovers things that machines can’t supply, and the contributions of even a brief physical exam can communicate humanity to the patient.

“I have always wondered how physicians can do telemedicine,” says Dr. Dickey, “because there is something about being there and being with the patient in terms of judging the severity of illness that is very important.”

“For all these reasons, it’s important for hospitalists to maintain their skills,” says Dr. Jauhar, “because otherwise we’re losing a big part of what it is to be a doctor. We’re just becoming technicians.” TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

  1. Bomback A. The physical exam and the sense of smell. N Engl J Med. 2006 Jan 26;354(4):327­­-329.
  2. Jauhar S. The demise of the physical exam. N Engl J Med. 2006;354(6):548-551.
  3. Markel H. The stethoscope and the art of listening. N Engl J Med. 2006;354(6):551-553.
  4. Treadway K. Becoming a physician: heart sounds. N Engl J Med. 2006 Mar 16;354(11):1112-1113.

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