Examining the Physical Exam
“Just get on the table and let me take a look.”
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Explore This IssueJuly 2021
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I’ve repeated that expression countless times during my career, generally after listening to a patient’s rococo description of their chief complaint. A quick listen with a stethoscope or a tap with a reflex hammer, and I can often reassure the patient they have nothing to worry about.
Because of the pandemic, that simple expression has become foreign to fellows. For a generation of rheumatology trainees, synovitis is the loss of hills-and-valleys between the knuckles rather than the sponginess beneath the fingertips. One of my fellows was beaming because she finally had the opportunity to perform scleroderma skin scores. In March.
When I was a medical student, I was forced to memorize a complete review of systems, called the Atchley Loeb form. Because of this form, my classmates and I learned to ask every patient whether fava beans made them ill, as a method of screening for glucose-6-phosphate dehydrogenase deficiency. When we complained about the length of the form, the course director opined, “Before you can take shortcuts, you need to learn, at least once, how to do it right.”
I have been thinking about this recently while working with trainees in my virtual clinic. As someone who has been doing this for a while, I feel like I might have the advantage, because I have seen the physical exam findings that my patients are now trying to describe to me.
I may be wrong. For example, I recently launched the proverbial million-dollar workup for a long-time patient who didn’t feel right. After I placed over a dozen orders for tests and consults, she elected to go to a local hospital, where she was diagnosed with pulmonary hypertension. I think I would have gotten there, eventually. But if she were in my clinic, I could have heard the accentuated P2.
Another patient had me convinced through the computer screen that his knee pain was due to his granulomatosis with polyangiitis. Fortunately, an orthopedic surgeon got his hands on my patient, literally, and realized he had a severe meniscal tear that was leaving his knee hot and swollen.
Interestingly, few data support a routine physical examination for the worried well. In an evidence-based review of physical exam findings, the U.S. Preventive Service Task Force found support for checking blood pressure, pap smear and body mass index once every few years.2 That’s it.
A 2019 Cochrane review of 15 randomized trials, including over 250 million patients, similarly concluded, “Systematic offers of health checks are unlikely to be beneficial … .”3
If you are otherwise healthy and have no known medical issues, you can safely forgo the routine physical.
You might even be better off—as evidenced by an essay written by an internist whose father underwent a very-important-person evaluation that led to the identification of an incidentaloma, which led to a biopsy, which almost killed him.4 The aforementioned Cochrane report concluded the routine physical examination may actually be harmful for the worried well, because it may result in unnecessary tests and visits that do not lead to benefit. Whoever first said the road to hell is paved with good intentions must have been a physician.
For patients who are worried and less well, however, the physical examination may still play an important role. Verghese et al. conducted a survey of 208 physicians who were asked to submit vignettes in which there was a clinical oversight.5 In 58% of cases, the oversight was due to creating a plan without examining the patient. In an additional 11% of cases, the patient was examined, but the relevant examination finding was misinterpreted. This led to a missed or delayed diagnosis in 76% of the vignettes, treatment delays in 42% of cases and unnecessary tests in 25% of patients.
As a program director, I find it particularly interesting to note that half of these oversights could be attributed to inadequate supervision of a trainee.
Despite my discomfit, no data support the idea that our patients suffer from receiving care through telemedicine. A recent study demonstrated that patients were perfectly capable of reporting their own tender joint count. Studies in orthopedic surgery indicate that an in-person evaluation rarely changed decisions initially made during a telemedicine appointment.
A systematic review of 233 studies of telemedicine in the inpatient, outpatient and emergency settings found:6