Monday, February 16, 2009

The Physical Exam

Pauline Chen has an interesting piece in last week's New York Times about the role of the physical exam in modern medicine. I must admit that as a medical student I was often frustrated by the physical exam. Likely, some of the frustration was due to a lack of confidence in my ability to perform some of the maneuvers. With practice this got better. After a month with an FP physician with a passion for sports medicine, for example, I was not afraid of patients with lower back pain anymore. He taught me a nice formula with a few simple tests to do each time that covered the range of motion of the entire back and pinpointed the location of the injury. Repetition does work.

A great deal of my frustration, however, I now realize was brought on by certain aspects of my training itself. During our first year we were taught physical exam skills in our Doctoring course. The course was taught by an NP who was very skilled at the physical exam and emphasized its importance. Smaller, more specialized parts of the exam were reinforced in our 2nd years coursework relating to organ system. By the time we hit the wards, I was pretty comfortable going leisurely through the motions on my classmates and the mostly healthy patients I saw at the student-run free clinics.

On the wards things were different. Everything moved much faster and the patients were often very sick. Residents were overworked and focused on collecting the volumes of data necessary for following the patients imaging, labs, and vitals. It was what Dr. Chen describes--spending a lot time touching the patient became low on the priority list. In rounds the physical exam was not usually emphasized. It was often brushed over to focus on imaging results. If a medical student brought up some exam maneuver to attempt it might be viewed with amusement as a relic of the past or as a teaching point. "Oh, that, well we rarely use that anymore since it is unreliable and we can just look at the CT, but why don't you try it when we go in to see the patient."

There were some exceptions to this seeming cultural norm, of course. On Trauma Surgery the physical exam carried a lot of weight, especially since initial treatment decisions often had to be made immediately and could not wait for imaging. On the wards I had one Internal Medicine attending who is very much like Dr. Abraham Verghese, the physician whose work that inspired Dr. Chen's article. With this attending all of the medical students went weekly on physical exam rounds and listened to the patient's stories in great detail. It was interesting and usually a more rewarding way of seeing patients than the usual rush-in, rush-out. Unfortunately, it was only once a week for a small part of my 3rd year.

So as I look back on my training it does not surprise me that as a medical student I tended to use the extra time I had with patients talking to them and not on performing detailed physical exams. I felt I could contribute more to their care by listening to them, being supportive, answering questions they felt had not been addressed, building rapport, and maybe even by finding some detail in their history that might have been missed. Perhaps the physical exam, as Dr. Verghese suggests, is another avenue for building trust with patients and finding the missing puzzle pieces to make the diagnosis. And with more emphasis on its importance in medical education and more physical exam teaching at the bedside, maybe the medical students who come after me will not find it to be the sometimes puzzling and frustrating experience that I did.


Christina said...

Hi there, I found your blog somehow or another and you know, I really relate to feeling a little lost when it comes to physical examination skills. As a medical student, we're rushed through learning how to examine patients systematically. During our clinical years in school and during residency, we're pressed for time, we're exhausted, lazy, etc...and we often gloss over learning good physical exam skills. Once, when I was working at a city hospital in Cleveland, I found that the foreign med grads often had MUCH better PE skills than American trained physicians. Likely this is because they do not have the technology that we so often rely on for diagnosis in the United States. It's sad really - and the pricey tests that we order are obviously driving up the cost of healthcare. It would be nice if we had more time to dedicate to honing our PE skills through out our training. One of my attendings recently said to me, "If you don't learn how to do it during residency, you'll never learn how to do it." So very, very true!

The Lone Coyote said...


I completely agree. I have not had much experience working with foreign graduates, but I have heard similar things from people who have done rotations abroad. And now that I am actually working in the lab, I am constantly astounded by how much things cost and how many unnecessary tests are ordered.