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.”
—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.