The physical exam is on life support: can it be revived?
Until the advent of CT scans and MTI Imaging in the 1970s, doctors relied on their senses – hearing, vision, touch and even smell to determine what was wrong with their patients. They were skilled in gleaning patients’ histories because they had the interest and the time to do so. The anchors of their diagnostic tool kits were simple gadgets they could carry such as a reflex hammer and a stethoscope.
Today, doctors talk to you sitting behind their computers, order expensive tests that may be unnecessary, miss out on vital information they can obtain immediately, and are unable to connect human to human because they have lost the art of the physical exam.
Abraham Verghese, MD, a professor of medicine at Stanford University School of Medicine, considers the body a text of sorts and considers the skilled physical exam essential basic medical literacy. His mission: to revive this kind of medical literacy nationwide.
To understand how vital it is for doctors to read patients’ physicality, follow Dr. Verghese as he examines a woman patient in front of four medical students. The doctor gently picks up the woman’s hand, pointing to a curious pattern – islands of intense redness on a background of pale white skin. He leads one student to feel a distinct raised and thickened tendon in the palm. Both those conditions occur in people with liver disease. Dr. Verghese says the woman’s pulse is so forceful it can be felt by just holding the wrist; this is called a “bounding pulse,” a sign of a wide pulse pressure that can occur with liver dysfunction. Further information is found on the patient’s skin just under her collarbone where red star-shaped markings fan out like threads of a spider web. These unusual blood vessel patterns are yet another sign of liver disease.
Dr. Verghese explains that being able to read and understand the body will enable doctors to “ask better questions of the tests we order.”
Another Stanford physician, Charlotte Jacobs, emeritus professor of medicine, agrees with Dr. Verghese about the need for doctors to be skilled clinicians. “I began practicing in an era when we didn’t have a CT scan. If a patient came to the ER with abdominal pain, a bedside exam was vital for determining whether they had appendicitis or some other condition. Now, a patient with abdominal pain may be shipped off to a CT scanner, which may – or may not – yield information of value. But often it is only the hand examining the patient that reveals where the patient is most tender and where the attention needs to be directed. The expensive new tools aren’t useful in every case, and for CT scans and some other imaging techniques, there’s a risk from radiation exposure to consider.”
The responsibility for doctors’ diminishing skill in doing a physical exam also lies with patients. Drummond Rennie, MD, a professor of medicine at UC-San Francisco and deputy editor of the Journal of the American Medical Association, says, “There is emphasis on tests in this country which is staggering. The American public has fallen in love with tests, no matter how harmful, useless and expensive.”
In addition to being able to see what is physically happening in the body, the physical exam (used extensively in countries such as Great Britain, Australia and New Zealand) is a ritual experience that has, in and of itself, a therapeutic benefit for psychological and physical reasons. The laying on of hands allows patients to relieve some of their stress and talk to doctors about what is really bothering them.
The writer of this article can testify to the life-saving value of a doctor with knowledge of the body. In 1980, my mother’s life was saved by her doctor (originally from India) who palpated her body and knew that her aorta artery was thinning and was going to burst. He had her operated on immediately; this doctor’s skill gave my mother another ten more precious years of life.
You are in a relationship with your doctor. Ask for what you want – a really comprehensive physical exam.
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