Wednesday, September 30, 2020

The Physical Exam: The next dodo?

Most experts who have looked at the relative value of the medical history, the physical examination and the findings of laboratory tests and imaging studies have come to the same broad conclusion. The medical history is by far the most important contributor to an accurate diagnosis; some 60 to 80% of the time, the history alone leads to the correct diagnosis. The physical exam generally contributes 12-20% of the needed information and laboratory/imaging results 10-20%. Both the physical exam and test results do increase practitioners’ confidence level that their diagnosis is correct.

You would thus expect that physicians would spend a lot of time taking a careful history and devote roughly equal time to doing a comprehensive physical exam and ordering and reviewing lab tests.

Alas, over the last few years my observations while accompanying friends and family members to medical appointments has been just the opposite. History taking is brief and appears to be largely devoted to “checking off” items such as smoking history and medications that are needed to complete the electronic chart. When patients start to tell their stories, the doctor typically interrupts in less than a minute.

As to the physical exam, it is charitable to call most I have witnessed cursory. Well-defined problems do not need a complete physical exam; if you are complaining of a sore throat, the doctor generally needs only check the inside of your mouth and your neck. Less well-defined problems such as weight loss or fatigue may need a classic head-to-toe exam. Even seemingly localized problems may need more than the obvious. Could your sore throat be mono? If so, checking for an enlarged spleen may be very useful.

You would expect hospital admission, reserved for the sickest patients, to require a thorough physical exam, as it was “in the old days.” What seems to pass for a complete physical these days seems to be listening to the heart and lungs and quickly feeling the upper abdomen. Rarely if ever do admitting doctors check the head and neck, and almost never is a breast or rectal exam done.

Instead the focus is on testing: “routine” blood work that gives little information and advanced imaging. The head echocardiography technician at a hospital where I worked once joked to me that the main reason residents ordered echocardiograms was that “the patient has a heart.” When ordered to follow up on a suspected diagnosis, imaging can be very useful; when ordered in a shotgun manner, it is equally likely to produce confusion and misinformation.

Patients, too, place more faith in CT scans and MRIs than in a good “H+P” (history and physical). That faith can be misplaced. Take back pain as a good example. Most people over 40 and almost everyone over 60 will have some abnormality when imaging is done of the spine. This includes people who have never had a backache in their life. All-too-often I have seen patients with muscular or arthritic back pain taken to surgery to fix an abnormality seen on a CT scan, and of course they were not benefitted in the least. A good H+P should strongly suggest the likelihood of a surgically curable source of back pain, and imaging can then confirm it, but the surgeon “who will not see me without a CT scan” is practicing poor quality medicine.

Worried about too much X-ray exposure? A recent study found that if you go to the Emergency Department with pain in your left lower abdomen, a simple combination of findings (absence of vomiting, presence of a fever and tenderness when the doctor presses on your abdomen that is only found in the lower left portion) makes a diagnosis of diverticulitis so accurately that a CT scan is not needed unless the doctor is worried about complications.

Let us not let the clinical exam, and in particular the physical, follow the dodo into extinction. Good history-taking skills and physical exam skills must be taught, and their use rewarded. We will see better results and lower costs.

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