Doesn’t anyone examine patients anymore?
I recently went to see a hospital patient signed out to me by another doctor. I was told that the patient, a 77-year-old woman, was admitted by her internist for weakness and weight loss. My hematology-oncology group practice was consulted because she had been treated sometime in the past with radiation therapy, as primary treatment for localized lung cancer.
While reviewing her chart, I noted that a bone scan showed uptake at the left sixth costochondral junction and that radiographs of this area showed sclerosis of the bone. I thought that I might be able to feel this on examination. Sure enough, there was a mass measuring about 3 cm in diameter at that very spot. The rest of her chest exam was also remarkable. Her breasts seemed to be misshapen, and, on palpation, it was obvious that she had saline implants.
Her sternum had a distinctly abnormal shape, as well. It had been eroded in the past by an infection postcardiac surgery. The skin over the sternum was horizontally taut at the sites of sutures placed at the time of her infection.
On returning to the chart, I found that the medical resident and five consultants had seen the patient, and not one had mentioned any abnormality of the chest wall. It turned out that the patient did not have the implants related to any cancer treatment, but at age 50, after five children, she had cosmetic breast surgery. In fact, I discovered that her nurse knew all about this prior surgery. I wrote my consultation and drew a picture of what I saw. I thought that an aspiration of the mass might enable us to define whether the patient had metastatic disease.
Later that day the patients attending physician saw me in the hallway. I saw your note. You did this to me when I was a resident, and it got me in trouble, she said. What do you mean? I asked. You found something on physical examination that I had not, and my instructors gave me a hard time about it, was her reply. We talked it over and agreed that the mass should be aspirated for diagnosis; however, the patient and her family refused the procedure, so I never found out if my interpretation of the findings was valid.
A pattern emerges
That same day, I saw a patient whose legs were so edematous that I thought they might start to weep edema fluid. The chart said, Extremities; no edema. The previous week I saw another patient whose hepatomegaly was at least six finger breaths below the right costal margin, yet several examiners had missed it. Did you feel that huge liver? I asked the attending. He obviously had not. No I didnt, but so what, I got a CT scan, he replied.
What is it about physical examinations that doctors are no longer interested in them? As internists, what could be more important? Physical findings often yield essential bits of information that allow the physician to focus his or her workup on what is the most likely etiology of the patients problem. Going online, I found two electronic sites where the topic of inadequate physical exams was discussed. The first, a Forum for Discussion, had 352 physicians lamenting and being angered by the fact that they or their patients did not have physical exams as part of their physician visits. At another electronic medical journal website, the authors wrote:
It has long been said that physicians order an increasing number of tests because we are practicing defensive medicine in an increasingly litigious environment. But, it is also likely that physicians order so many tests because we have lost confidence in our abilities to extract meaningful information from the physical examination. In particular, physicians seem to lack the confidence to say that an examination of a certain body part is normal, and no further testing is needed. Despite a growing body of literature questioning the value of the routine examination, this aspect of the physician-patient encounter is clearly valued by the patient. In one study, 90% of patients expected their blood pressure to be measured and their heart, lungs, abdomen and reflexes be examined. Even if routine examination may not be essential to actual patient care, we believe the skilled examination is critical to the development of the physician-patient relationship. Done well, it earns trust, patient confidence and perhaps increasing patient compliance.
Well said. I couldnt agree more.
Arthur Topilow, MD, is in private practice at Atlantic Hematology & Oncology in Manasquan, N.J.
For more information:
- Web MD, Physician Connect. Physical exams no longer necessary? Physician Discussion>Clinical>Internal Medicine. Accessed Dec. 30, 2008 at http://boards.medscape.com/forums?50@@.29ee29a1/0.
- AHRQ. WebM&M (Morbidity and Mortality Rounds on the Web). Thompson III GR, Verghese A. Spotlight case: Physical diagnosis: a lost art? Medicine. August 2006. Accessed at: www.webmm.ahrq.gov/case.aspx?caseID=131.