Medical Student Perspectives: Is the Physical Exam Dying?
The future of the physical exam has come into question again in both the scientific journals and the popular press. For the last decade or longer, the debate has raged over the value of the annual physical exam. A study by the Agency for Healthcare Research and Quality (AHRQ)1, which began in 1989 and was published in 2006, is commonly cited by opponents of the annual physical. This systematic review found little evidence that the annual physical exam improved clinical outcomes. Many saw this report as a clash of evidence-based medicine and the art of medicine because it seemed to call into question an age age-old practice. Interestingly, a New York Times article in 2003 reported that physicians who helped perform the study continued to offer annual physical exams because of the ritual of the doctor-patient relationship2. The most recent news is being made by physicians who have chosen to stand up and fight for the value of the physical exam in medical education. As medical students who plan to go into Internal Medicine, a field where the physical exam is still used most often, it is up to us to decide if we believe the physical exam is dying; and if so, should it be resurrected?
A National Public Radio (NPR) article in September 2010 entitled "The Fading Art of the Physical Exam"3 highlights the opinions of Stanford Medical School Professor Abraham Verghese, MD, MACP, and others who see physical exam skills fading in the face of new diagnostic technology and electronic medical records. Verghese is better known as the author of My Own Country and The Tennis Partner among other books, but he has also been a prolific and ardent advocate of the physical exam. For example, his article in the British Medical Journal extols the benefits of the physical exam and outlines 25 exam skills that Stanford Internal Medicine residents are expected to master through their training4. The NPR article reports that Verghese is not only convinced that the physical exam picks up some potentially missed diagnoses but that it also offers a healing touch. He may be right on both accounts. A study published by Reilly, et. al. in The Lancet in 2003 found that out of 100 patients in a single hospital, 26 had pivotal physical findings and 7 had physical findings of disease that would not have been picked up by other modalities5. The intrinsic benefit of the physical exam derived through physician-patient contact has been much more difficult to quantify, but several articles have cited the power of touch in the physician-patient relationship, including the August 2010 New York Times6 piece written by Dr. Danielle Ofri, MD, FACP.
Critics of the importance of the physical exam have spoken against its diagnostic accuracy in comparison to other diagnostic technology. Indeed, many of the "gold standards" for diagnosis involve radiologic imaging or laboratory testing. Many doctors who use the physical exam might still order laboratory tests or imaging when they expect to find nothing, "just in case". Technologic advances may indeed have sharpened physicians' diagnostic accuracy and efficiency, but perhaps the physical exam need not be discarded by this scientific evidence. Some scholars have explored how the process can instead be refined using the principles of evidence-based medicine. Steven McGee, MD, FACP, is the author of Evidence-based Physical Diagnosis, and his work has been to study the efficacy of traditional physical exam maneuvers to predict disease7. His book is dedicated to quantifying the predictive accuracy of different techniques in terms of the likelihood ratio (LR). By using physical exam maneuvers that have a high or low LR, doctors can significantly change the post-test probability of the presence or absence of a disease. If a physical exam test has an LR close to 1, it is unlikely to affect the pre-test suspicion, and the physician can increase his or her diagnostic efficiency and accuracy by excluding it. The use of the evidence-based physical exam can also make physicians more confident in their assessment of the need for further testing. Another great resource for the predictive value of disease-specific exam maneuvers is JAMA's The Rational Clinical Examination8.
So as future Internists, what do you think about the value of the physical exam? Is molecular medicine outpacing the need for exam skills? Is the physical exam an innate and irreplaceable part of being a doctor? Should we spend more time training in physical diagnosis beyond the first part of medical school? Our answers to these questions will determine not only the way we practice medicine but the future of the physical exam as well.
Council of Student Members Representative, Midwestern Region
University of New Mexico School of Medicine, 2011
1. Boulware et al. Value of the Periodic Health Examination.
AHRQ Publication No. 06-E011. April 2006.
2. Kolata, G. Annual Physical Checkup May be an Empty Ritual. New York Times. August 12, 2003.
3. Knox, R. The Fading Art of the Physical Exam. National Public Radio Online. September 20, 2010 Accessed at www.npr.org on 9/22/10.
4. Verghese and Horwitz. In Praise of the Physical Exam. BMJ 2009; 339:b5448.
5. Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet 2003 Oct 4; 362(9390):1100-5.
6. Ofri, D. Not on the Doctor's Checklist, but Touch Matters. New York Times. August 2, 2010.
7. McGee, S. Evidence-Based Physical Diagnosis. Second Edition. Saunders 2007
8. Simel and Rennie. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. McGraw-Hill 2009.