Physical Exam

August 19, 2007

I think that most patients feel that the most important part of a doctor visit is the physical exam. It is when we actually lay hands on the patient and "find out what is wrong." In the flow of the visit it seems to be the climax of data-gathering. We first ask questions, then we assess whether the hypotheses we put forth are really true.

Actually, I see the physical as ten, maybe twenty percent of my decision making. Most of it comes from the history - the questions I ask before the visit. I know that when I am seeing the patient, I am seeing them at one moment in time. The history, on the other hand, covers all the time leading up to today’s visit. Many conditions are intermittent, or are difficult to tell anything on exam, so the exam gives very little additional information than that which is gathered in the history.

This being the case, when I was early in my practice, I sometimes wondered if I could just see the patient without doing an exam. If I gathered all the information I needed, why did I have to go through the ritual of an exam? This is more to the point when it comes to the modern trends in medicine. Why should a patient have to come in to be seen, when a medical problem (a urinary tract infection, for instance) could be handled via e-mail? What is the value of actually seeing that person face-to-face?

While I do see that there are some points to this school of thought, thirteen years in practice have taught me that it is just when I don’t expect things, that is when they show up. Despite the fact that the physical exam seems like a "waste of time," I have learned to see value in it even when I find nothing that adds to my decision-making.

One of the most important things in being someone’s doctor is that they put their trust in you. There is a bond that can form between a patient and their doctor that goes beyond a professional relationship. They are entrusting you with the most important thing - their life. One of the main ways you draw close to a patient is to break down the physical barriers of distance. When you listen to their heart and lungs, feel their pulse, and look in their ears and mouth, you are sharing something with them that only they possess. You are symbolically entering the world of their life. I believe this is part of what wins our trust.

So often I end up doing an exam, more as an act of symbolism than to actually learn something. I go through the ritual of looking in the ears and mouth, feeling the neck, and listening to the heart and lungs - all with little expectation of finding things.

Yet this ritual serves another purpose: there are times when the unexpected whacks you in the face. The fact that I have done at least 100 exams per week for the past 13 years, means that I have a whole lot of "normal" by which to judge my abnormals. Sometimes the persistent cough is actually accompanied by wheezing. Sometimes the chest pain is due to a collapsed lung. Rare things still do happen, and although you don’t ever expect them, you need to give yourself the chance to find them. My "ritual" exams have found quite a few surprises.

The advent of imaging technology, lab tests, and other diagnostics has definitely diminished the importance of the physical exam. In the past, doctors could only rely on their own exam skills to accurately make most diagnoses. While that has waned, I don’t believe we will ever escape the need for a hands-on exam by a skilled physician. There is far too much to be gained from direct contact between patient and physician for the practice to be replaced by algorithms.

If that ever does happen, I may just quit being a doctor.

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