Death of the Physical? Primary Care and its ‘Archaic’ Exam

Dr. Eric Topol’s Technology, Innovation, and Design (TED) talk entitled, “The Wireless Future of Medicine”, discusses how we will soon use smartphones to monitor our vital signs, diabetes, and even our REM cycles.1 The goal, as Dr. Topol reiterates to his audience, is to keep more patients out of hospital beds.  Yet, critics claim that this sort of medical technology further distances the doctor from the patient and sacrifices the most holy of all exams: the physical.  Moreover, such innovation threatens the administrator of the physical exam, the primary care doctor.  For example, WebMD, Healthline, and even hospital websites pride themselves on having “Better information [and] better health” than mainstream medicine.2 Yet, this technology cannot feel the preliminary stages of an aortic aneurysm, hear a mitral valve prolapse, or recognize a melanoma from a seemingly benign mole.

On one side are the progressives, who argue that the demise of the physical exam is a natural consequence of evolution in medical technology.  On the other side are the romantics, who cherish the sacred relationship between the doctor and patient.  Perhaps both sides are a bit radical, and any reasonable doctor probably lies somewhere in the middle.  There was surprisingly little research on this question until Dr. Brendan Reilly showed that a careful physical exam changed the patient’s diagnosis and treatment in 26% of cases that were reviewed by his team.3 This study, along with others, suggests that a thorough physical examination plays a critical role in making a diagnosis—one that cannot be replicated by even the most sophisticated test.  The question is, then, which parts of physical diagnosis are worth saving and which parts should be disposed?  And once this is solved, how can we incorporate this sort of change into medical education?

There is no doubt that technology has advanced medicine more than it has forwarded any other field, except the military.  After CT scans, MRI machines, pacemakers, and hip or knee replacements emerged in the past fifty years, it is no surprise that the United States invested $140 billion dollars in medical research last year.4 Yet, of all the technology that has been developed, perhaps none have changed healthcare as much as one recent invention—the Internet.  Why?  The Internet has equalized the control over diagnosing and treating illness.5 Traditionally, aside from personal anecdotes from family and friends, the doctor was the primary source for diagnosing and treating illness.  Now, ‘googling’ symptoms has led patients to medical journals, clinical studies, physician evaluations, chat rooms, and, in many cases, horror stories.

Physician evaluation websites like Healthgrades, Everyday Health, and Vitals offer a 5-star rating for individual physicians.  Of course, like any political poll or review, these evaluations introduce an overwhelming amount of statistical bias. While these online sources certainly provide some thoughtful and honest information, false claims are just as easy to upload.  Unfortunately, once a site purports a falsehood to be true, hyperlinks direct the patient to other sites that reinforce that falsehood, and physicians have no opportunity to dispute a poor rating or comment.6 Thus, the patient relying on these sites about their physician is led to believe potentially false information.

Moreover, under the banner of individualized medicine, which several hospitals promote, the Internet has allowed self-diagnosis to replace the physician.7 That is, instead of equalizing the control over the diagnosis and treatment between the physician and patient, the Internet has completely shifted the control to the patient, in many cases.  Sometimes, this has led patients to suggest a correct diagnosis.  However, for hypochondriacs, this has amplified their anxiety over their health issues and has led to an overwhelming reliance and trust in the easily falsifiable Internet.5 A study in the New England Journal of Medicine showed that Google found the right diagnosis for only 15 out of 26 cases (58 percent).8 Besides showing that Google flunked its ability to diagnose, the authors of the study also discovered that Google was more accurate for diseases that had unique symptoms and less accurate for “normal” symptoms.8 This is important because patients have relinquished their dependence on doctors to diagnose even normal symptoms.  At the fundamental level, they have replaced the hands-on, low-tech physical exam with the high-tech, hands-off Google search.  Yet, can we blame patients for killing the physical?

In 2004, the Accreditation Council of Graduate Medical Education (ACGME) mandated the eighty-hour workweek for residents.9 Yet, the amount of work for residents has not decreased, only the amount of time to perform it.  Thus, the work that is sacrificed by this mandate is the amount of time that residents spend with patients.  For example, at Yale University, interns are not permitted to come to the hospital any earlier than one hour before work rounds.10 This means that less time is spent with patients examining, feeling, hearing, and, ultimately, learning what ‘sick’ looks like.  In addition, the amount of time that patients spend in the hospital has gone from a ten days in 1980 to six in 2008.11 While this is a triumph for medicine in general, there is less opportunity to do bedside teaching for students, interns, and residents.  Lastly, and perhaps the most telling statistic of all, only one in four medical schools offer structured teaching of physical examination skills.12 The usual response is that, in the “unwritten curriculum”, which says how medicine is actually practiced, the physical exam is a waste of time.10 It makes sense, then, that patients will forgo the physical in favor of the Google search.

Moreover, misdiagnosis is the second leading cause of malpractice suits against hospitals.13 Naturally, physicians will often skip the physical in favor of the ‘infallible’ CT scans, MRIs, and other expensive tests.  In addition, Dr. Steven McGee’s studies have shown that some well-known, frequently taught parts of the exam are worthless.14 For example, listening to the lungs will rarely help a physician decide if a patient has pneumonia.  From a physician’s point of view, the physical is a waste of time and, more importantly, just another way to get in legal trouble.  Thus, can we blame physicians for killing the physical?

Yet, a closer look at the exam suggests that there are several symptoms and presentations that only the exam can reveal.  Cardiac exams, for example, can identify problems in the valves almost as well as echocardiograms.12 Furthermore, Dr. Brendan Reilly’s study shows that the physical actually makes a difference in the diagnosis.3 His team reviewed 100 cases looking for something that was found on the physical exam that changed the diagnosis and the treatment of the patient.  He found that, in 26 cases, the physical changed the diagnosis and treatment.  In half of these cases, if the physical exam had not found the correct diagnosis, “reasonable testing” would not have found it either.  Another statistic reveals equally impressive results.  70% of breast cancers are detected by patients themselves, 20% are detected by a mammogram, and physicians detect 5%.15 While this may seem marginal, given the unfortunately high number of breast cancers in the U.S., the physical exam discovers up to ten thousand cancers every year.

The question that remains, then, is what medical schools should do to reintroduce the physical exam into the curriculum.  Dr. Lisa Sanders suggests that medical education should work to reestablish our “fascination with the abnormal” that existed in our childhood.10 For example, as children, people who appeared different than what we expected to see fascinated us.  We had no problem asking someone if he or she were a man or a woman, how old he or she was, or what that red rash on his or her thigh was.  Naturally, says Sanders, our parents trained us to avoid such questions because they were offensive.10 Thus, in order to resuscitate the physical exam from its struggling state, medical schools must teach their students to return to that childhood fascination with the abnormal.  It is no coincidence that Dr. Sanders is the technical advisor to House, M.D.—the television show based on Sherlock Holmes, whose character in turn was based on Dr. Joseph Bell, whose fascination with the abnormal led to remarkable diagnoses in the late 19th century.

One positive development is the reinstitution of a clinical skills portion on the United States Medical Licensing Examination—the exam that doctors must take before they can practice medicine.  Beginning in 1916, the exam required an evaluation of a patient, observed by a physician-grader [10].  However, this portion was dropped in 1964 because it was difficult to standardize such a setting.  Interestingly, the clinical skills portion returned in 2005. Most likely, this happened because of poor physical exam skills of current physicians.  Yet, on a deeper level, perhaps this change also reflects a concern about the rising cost of healthcare.  While innovations in medical technology have saved millions of lives, it is no secret that they have also dramatically increased costs.16 A revival of the physical exam does not ignore such technology, but rather accompanies it in a cost-effective manner.  This is because the physical exam differentiates those who need testing and those for whom testing is a waste of time and money.

Thus, the value of the physical cannot be overlooked in modern medicine.  The success of the rapid evolution in technology, though saving countless lives, has raised healthcare expenditures as rapidly as the innovations that have been created.  The physical exam provides a cost-effective strategy that returns the doctor to his or her rightful place as the primary healer and teacher for patients.

References

  1. Eric Topol M.D., “lecture,” TEDMED 2009, performed by Dr. Eric Topol, Octo 12, 2011, Web, http://www.ted.com/talks/lang/eng/eric_topol_the_wireless_future_of_medicine.html.
  2. WebMD, “WebMD. Better Information. Better Health.” Accessed November 4, 2011. http://www.webmd.com/.
  3. Brendan Reilly M.D., “Physical examination in the care of medical inpatients: an observational study,” The Lancet, 362, no. 9390 (2003): 1100-05.
  4. 2010 U.S. Investment in Health Research.” Research America An Alliance for Discoveries in Health. : 1-4.
  5. Pamela Hartzband M.D., and Jerome Groopman M.D., “Untangling the Web-Patients, Doctors, and the Internet ,” The New England Journal of Medicine, no. 362 (2010): 1063-66.
  6. Sunstein CR. On rumor: how falsehoods spread, why we believe them, what can be done. New York: Farrar, Straus & Giroux, 2009.
  7. Mayo Clinic, “Individualized Medicine.” Last modified 2001. Accessed November 4, 2011.
  8. Tang H, Ng JHK. Googling for a diagnosis — use of Google as a diagnostic aid: Internet based study. BMJ no. 333 (2006): 1143-1145.
  9. “Duty Hours Language.” Accreditation for Graduate Medical Education. (2007).
  10. Lisa Sanders M.D., Every Patient Tells a Story, (New York: Broadway, 2009).
  11. “Hospital admissions, average length of stay, outpatient visits, and outpatient surgery by type of ownership and size of hospital: United States, selected years 1975–2008.” Data from CDC. (2010).
  12. Salvatore Mangione, LZ Nieman.  “Pulmonary auscultatory skills during training in internal medicine and family practice. Am J Resp & Crit Care Med no 119 (1993): 47-54.
  13. EE Bartlett.  “Physicians’ cognitive errors and their liability consequences.” J Healthcare Risk Management 1998: 62-69.
  14. McGee, Steven. Evidence Based Physical Diagnosis. St. Louis: Saunders Elsevier, 2007.
  15. Breast Cancer Foundation, “Breast Self-Exam (BSE)” Accessed November 4, 2011. http://www.nationalbreastcancer.org/about-breast-cancer/breast-self-exam.aspx.
  16. CBO Testimony. “Health Care and the Budget: Issues and Challenges for Reform” 21. June 2007.  Congressional Budget Office.
  17. Image credit (public domain): Smith, Timothy. “Oral surgery is performed on an Indonesian Man.” US Department of Defense. Last modified February 18, 2005. http://www.defense.gov/photos/newsphoto.aspx?newsphotoid=6167
  18. Image credit (Creative Commons): Cathdew. “Sick.” Flickr. Last modified June 18, 2009. http://www.flickr.com/photos/zomerstorm/3637754215/
  19. Image credit (public domain): Nuzzo, Joshua Adam. “Physical Examination of a Boy.” Wikimedia Commons. Last modified September 20, 2008. http://commons.wikimedia.org/wiki/File:Physical_Examination_of_a_boy.jpg

Jacob Ripp is an undergraduate student at Georgetown University. Follow The Triple Helix Online on Twitter and join us on Facebook.

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