COMMENTARY

Decline of the Physical Exam: Clinical Tragedy or Good Riddance?

Medscape held a Medicine 3.0 town hall event on Technology, Patients, and the Art of Medicine on July 20, 2017. Following are excerpts from the panel discussion.

Dr Verghese: I concur with you that our physical examination skills are declining. I think that in part it's because we're spending so much time at the computer. It's in part because ward rounds, in general, are not as valued as they should be, and we don't get as many options to model care at the bedside because everybody's being pulled off in many different directions. It's a challenge that every academic medical center is dealing with.

Eric J. Topol: They were "card-flip" rounds. Now what are they - iPad rounds?

Dr Verghese: I think there's a lot of card-flip rounds. A lot of massaging data. Residents are not unwilling to go to the bedside with us, but we need to free them up to be able to go so that they're not tied to the computer and then have to scramble and do more work because they wanted to hold fort on the signs of endocarditis for half an hour. We have to be cognizant of that.

I agree with you. I think we're in great danger. We published a paper[1] on oversights in the physical exam that led to all kinds of consequences. They happen every day in every medical center. It's something that we have to address, and finding a better way to record what happened is, I think, the way to go.

Michael S. Blum: Let me be a little bit provocative. I agree with you that, in your statement, there's incredible value in touching the patient, talking to the patient, and developing that rapport. There's no question about it.

Physical exam skills are eroding fairly significantly. We see that year after year. The masters who taught us are gone, and we're not teaching the people below us well enough, for all the reasons we talked about.

At the same time, we grossly overestimated the average clinician's ability to do an extremely good physical exam and to make all of the relevant physical findings. It has been documented over and over again that the average person's ability to use a stethoscope and document a murmur accurately is a coin flip. The ability of the average house officer to do volume assessment based on a physical exam is terribly low.

We now have handheld technology with which we can walk around and see how engorged the veins are. You can see exactly where the levels are. It doesn't make sense any longer to spend the 5 minutes standing at the bedside doing those old maneuvers; when you stick the [handheld device] on there, you know what the answer is, and then you spend the 4.5 remaining minutes talking to the patient. Arguing about what kind of murmur you're hearing when an echo is going to tell you what's going on is kind of silly when we can spend that time much better, doing the things you were talking about.

We need to not embrace the old lore of the "wonderful physical exam" and "the time I was a resident and saved this guy's life, because I saw this thing." That's all nice, but to take care of huge numbers of patients and to do it efficiently, we're going to need to use the new tools and give up some stuff. I know it was super cool when you were training.

Dr Topol: I'm glad you mentioned that, because we're fans of smartphone ultrasound or pocket ultrasound because of that. I used to spend umpteenth hours on the split-second heart sound at the bedside and whatever other sound. Now, why would you do that? Why would you do any of that today? Of course, most physicians don't feel that way.

(Participants: Eric J. Topol, MD; Abraham Verghese, MD; Michael S. Blum, MD; Jessica Mega, MD, MPH)

References
1. Verghese A, Charlton B, Kassirer JP, Ramsey M, Ioannidis JP. Inadequacies of physical examination as a cause of medical errors and adverse events: a collection of vignettes. Am J Med. 2015;128:1322-4.e3.

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