Patients Lose When Doctors Can't Do
Good Physical Exams
This is a story important to all seniors, who are the primary consumers
of health services and those most often in need of careful medical
attention. Caregivers, too, should be attentive to this trend.
May 20, 2014 - Doctors at a
Northern California hospital, concerned that a 40-year-old woman with
sky-high blood pressure and confusion might have a blood clot, order a
CT scan of her lungs. To their surprise, the scan reveals not a clot but
large cancers in both breasts that have spread throughout her body.
Had they done a simple physical
exam of the woman's chest, they would have been able to feel the tumors.
So would the doctors who saw her during several hospitalizations over
the previous two years, when the cancer might have been more easily
A middle-aged man admitted to a
Seattle emergency room for the third time in six weeks displays the
classic signs of liver cirrhosis for which he has been repeatedly
treated, including swollen legs and a distended abdomen.
But a veteran doctor spots a
telltale indicator of a different disease: rapid inward pulsations just
beneath the man's right ear. The patient's problem is not his liver but
his heart: he has constrictive pericarditis, a serious condition that
Both cases reflect a phenomenon
that some prominent medical educators say has become increasingly
commonplace as medicine becomes more technology-driven: the waning
ability of doctors to use a physical exam to make an accurate diagnosis.
Information gleaned from inspecting blood vessels at the back of the
eye, observing a patient's walk, feeling the liver or checking
fingernails can provide valuable clues to underlying diseases or
incipient problems, they say.
But over the past few decades the
physical diagnosis skills that were once the cornerstone of doctoring
have withered, supplanted by a dizzying array of sophisticated,
"A lot of people downplay the
physical exam and [wrongly] say it's fluff," said Salvatore Mangione,
associate director of the internal medicine residency at Philadelphia's
Jefferson Medical College and director of its physical diagnosis
A Skill Set For Doctors
components of a physical exam are familiar, such as listening to
the lungs and heart, and assessing blood pressure and pulse.
parts of the Stanford Medicine 25 -- a list of skills that the
school considers important for doctors to know how to perform --
may be less familiar. Below are some of those beside tests:
Feel lymph nodes and differentiate benign enlargement from
Evaluate patient's walk for signs of neurological or
Inspect the tongue for the presence of infection or underlying
Feel the thyroid gland and palpate the spleen to check for
Assess the liver, checking for tenderness and enlargement, and
recognize signs of liver disease elsewhere in the body.
Evaluate tremors and involuntary movements.
Examine fingernails for signs of kidney, heart or lung disease
or nicotine use.
In a 2012 article in the Cleveland
Clinic Journal of Medicine, Mangione wrote that he has seen "many cases
in which technology, unguided by bedside skills, took physicians down a
path where tests begot tests and where, at the end, there was usually a
surgeon, and often a lawyer. Sometimes even an undertaker."
To address the problem, programs to
revive and teach physical diagnosis - also known as bedside medicine -
are underway at some medical schools, including Stanford, Jefferson and
The programs are predicated on a belief that these skills
are an essential adjunct to technology and can boost diagnostic
accuracy, curb unnecessary and expensive testing and foster a greater
connection between patients and doctors, many of whom spend increasing
amounts of their day staring at their computers rather than looking at
the patients they are treating.
At Hopkins, a Web-based program
called Murmurlab.org seeks to improve young doctors' ability to use a
stethoscope -- a tricky skill that studies have shown is lacking - to
distinguish serious cardiac problems from far more common benign heart
The goal is to reduce unnecessary
and costly echocardiograms.
"There are two reasons it remains
crucial to do this [physical diagnosis] at least as well as doctors did
100 years ago," said internist and best-selling author Abraham Verghese,
senior associate chairman of Stanford's program on the theory and
practice of medicine. Verghese was instrumental in creating the
six-year-old Stanford Medicine 25 program: 25 physical exam skills that
students are required to learn, demonstrate and teach. These include
assessing enlarged lymph nodes, measuring ankle reflexes and performing
a knee exam.
"We can pick off the low-hanging
fruit - the obvious diagnosis that one can miss at great cost to the
patient," such as the woman whose metastatic breast cancer was
repeatedly missed, Verghese said. In his view, the physical exam also
represents an "important transactional moment" between doctor and
patient - a laying-on of hands that helps foster trust. An increasingly
common complaint from patients, he said, is that "the doctor never
Overreliance on technology, he
said, has produced perverse results. "If you come to our hospital
missing a finger," he quipped, "no one will believe you until we get a
CT scan, an MRI and an orthopedic consult."
Differentiating heart murmurs
But some experts are skeptical that
reviving the physical exam is the best approach in the 21st century.
Robert Wachter, former chairman of the American Board of Internal
Medicine, said he shares Verghese's concerns about declining clinical
skills. But Wachter said he isn't sure that "restoring the physical exam
of yore" is a solution.
"Taking time and energy to train
doctors in the physical exam may be less valuable than teaching them how
to communicate or to analyze . . . data," said Wachter, associate
chairman of medicine at the University of California at San Francisco.
"You've got to make some choices."
There is general agreement that the
technological explosion that began in the 1980s led to the decline of
Insurance that pays for tests but
gives short shrift to a careful and time-consuming history and physical
exam accelerated the trend, as has the growing paperwork burden doctors
face. The generation of influential mentors who taught physical
diagnosis has largely retired. Even bedside rounds - where such
knowledge was often imparted to impressionable neophyte physicians --
are mostly a thing of the past, migrating from a patient's hospital bed
to a conference room down the hall where test results and the chart --
not the actual patient -- are examined.
Too often, physical exam skills are
dismissed as inferior relics of the past when compared with "the glitter
and perceived objectiveness of modern technology," said Steven McGee, a
professor of medicine at the University of Washington and the author of
a recent textbook on evidence-based physical diagnosis.
McGee said that studies have found
that physical exam findings can be as accurate as their technological
counterparts. Case in point: A pair of studies involving 185 acutely
dizzy patients found that the presence of certain abnormal eye movements
were more accurate than an initial MRI scan in distinguishing a serious
stroke from a benign inner ear problem.
The enormous amount of technology
that doctors now must master has crowded out physical diagnosis, he
said. But, he noted, "there is a giant chunk of diagnosis that still
depends on what we see and detect" through observation and a physical
For a surprising number of
diseases, McGee added, diagnosis is based on observation and
examination, not a test. Among them are Parkinson's disease, shingles,
drug rashes and constrictive pericarditis.
These days, medical students often
train on actors who are only pretending to have medical problems, notes
Poonam Hosamani, a newly minted hospital-based internist who joined the
Stanford team last year.
Hosamani said that she recently
enlisted her husband, who has a bad knee, as a featured patient. Many
students told her they had never seen a patient with a knee problem.
"When we bring in patients with real pathologies, the students are very
excited about that," she said. "We have to show them that this is worth
their time and demonstrate how much information you can gain" through a
good exam, which is not intended to replace technology but to guide its
Internist John Kugler, an assistant
professor of medicine at Stanford, said that typically medical students
learn diagnosis skills before they have seen patients. "They are taught
where to put their hands, but these techniques are taught in isolation
and there is little to no reinforcement," he said.
W. Reid Thompson, a pediatric
cardiologist at Hopkins, launched Murmurlab, a website containing the
normal and abnormal heart sounds of more than 1,300 people, in part to
curb unnecessary referrals for echocardiograms, which cost up to $900
Heart murmurs in children, Thompson
said, are common -- between 60 and 70 percent of children have them --
but only about 1 percent are problematic. Distinguishing "innocent"
murmurs from serious ones, he said, is an essential skill for
physicians, not just cardiologists. But studies have repeatedly found
that many doctors do a poor job with auscultation, or listening to the
heart and lungs with a stethoscope.
Despite doctors' reliance on a
plethora of sophisticated tests, auscultation remains "a fundamental
clinical skill," Thompson says. "Every day . . . I walk up to a patient
and the first thing I do is listen" to the heart. "People walk around
with a stethoscope not just because it looks good or is expected, but
because there is information to be learned."
But Thompson said it is not yet
clear whether Murmurlab has improved doctors' skills. Stanford officials
say they are attempting to devise ways to measure the impact of their
program as well.
Lots of data, little
In a recent essay, Arnold Relman, a
former editor of the New England Journal of Medicine, described the
months he spent last summer at Massachusetts General Hospital after he
broke his neck in a near-fatal fall. "Doctors now spend more time with
their computers than at the bedside," wrote Relman, an emeritus
professor of medicine at Harvard. Reviewing records of his hospital
stay, Relman "found only brief descriptions of how I felt and looked"
but "copious reports of the data from tests and monitoring devices."
Conversations with his doctors were "infrequent, brief and hardly ever
McGee said that he once saw a nurse
tell a resident that a patient had spiked a fever and watched as the
young doctor frantically scrolled through the electronic medical record
searching for a cause, instead of walking down the hall to the patient's
room to discover the reason: an inflamed IV site.
"In most hospitals today, the
average amount of time a busy intern spends with a patient is four
minutes," said Brendan Reilly, who until recently was the executive vice
chairman of medicine at New York-Presbyterian Hospital.
No longer are
tests ordered based on the results of a careful physical exam and
history, Reilly said, but the "technological tests become the primary
source of information on the patient. It's backward now," and the
process is driving up health-care costs and subjecting patients to the
risks posed by sometimes unnecessary, risky procedures.
"Doctors trained outside the U.S.
are much better clinically than young American doctors," said Reilly,
the author of "One Doctor," an unsparing 2013 account of his medical
career. They are trained -- or forced by circumstance -- to rely less on
technology and more on physical diagnosis skills.
The Stanford Medicine 25 program
reflects Verghese's medical training in Ethiopia in the 1980s. Doctors
were required to hone their clinical skills because technology was
"In some ways," Reilly said, "what
Verghese is doing is opening people's eyes and showing that medicine can
be a lot of fun."
Reilly said he hopes the
accountable care organizations that are part of the new health law -
groups of doctors that band together with hospitals to improve the
quality of care for patients and share in cost savings - might boost the
effort to revive bedside medicine. "The current system is so ridiculous
and inefficient and expensive that we're going to have to go back to
doing some of the old stuff."