The Future of the Physical Exam
There are many reasons why the physical examination seems to have become less prominent in healthcare. To many, the physical exam is inexact, imprecise or outdated. Much of the support behind the physical exam appears to be received wisdom that contradicts our modern paradigm of evidence-based practice. Making matters worse is that the greatest evangelists for the physical examination tend to also be on the more senior side. Appeals to reinstate the physical examination are often heavy-handed, with a “kids these days!” subtext. Given all these factors, it seems like the physical exam is a thing of the past, unable to compete with the highly precise laboratory and radiographic studies that we now rely upon.
The truth is the contrary: The physical examination endures and evolves with the times. It accommodates scientific and technological advances, if we give it an opportunity to do so. Already, cardiologists utilize digital stethoscopes to better pick up the sounds of murmurs, gallops and rubs.10 In rheumatology, point-of-care musculoskeletal ultrasonography is arguably more an extension of the physical exam than a radiographic study.11 And of course, many of the disease activity scores that we use for treat-to-target strategies employ the physical examination as part of the criteria.
I am eager to see how large datasets redefine our diseases based on phenotypes. Correlation of radiographic, serologic and genetic data with physical manifestations of disease may lead to clinical insights that will be invaluable for upholding well-being. Artificial intelligence, either in the detection of physical exam signs or the interpretation of the physical examination, may also be a way to bring a longstanding tradition into the 21st century and beyond.
Intriguingly, the advent of telerheumatology brings with it great opportunities to reconsider what it means to do the physical exam without touch.12 Although I remain skeptical about whether the telerheumatology physical examination can ever replace the in-person physical examination, there are great advantages of telemedicine with respect to the physical exam. Crucially, the ability to observe a patient in their home environment is something the in-person physical exam simply cannot deliver.
Who’s Examining Whom?
There is one last reason that I strongly advocate for the musculoskeletal physical examination, and oddly enough, it has little to do with the patient. The musculoskeletal physical exam is good for the soul for the clinician. Clinicians in the U.S. are stuck in a dystopian world with prior authorizations, Press-Ganey scores, RVU targets, inbox messages, maintenance of certification and a million other things that seem to degrade the worth of our profession. All these things make it hard to remember why we entered this profoundly special field that emphasizes humanism and feeling.
