Normally, I provide an introduction to the topic of these presentations, which are focused on timely and important issues related to clinical practice. Today I'm going to break that format because I have a guest who has gone above and beyond in advocating for the role of a solid physical examination as part of the clinical encounter. Dr Fabrizia Faustinella is an MD/PhD, with a title of associate professor of internal medicine at the Baylor College of Medicine. She has led efforts to teach and evaluate the physical exam for medical students at Baylor and the University of Texas. Fabrizia, can you please share some of your observations on the physical examination in clinical practice? Fabrizia Faustinella, MD, PhD: Thank you, Chuck, for the opportunity. I really believe that there is a general consensus that clinical skills, history-taking skills, and physical examination skills have progressively deteriorated during the past 10 years and even longer. Bedside medicine is really in danger. There is consensus that action has to be taken to remedy the situation. Too Much Testing, Computer Time Dr Faustinella: In the past, Medscape has brought attention to this widely debated topic in a number of articles. The reasons behind the deterioration in both physical examination and history-taking skills are very complex and represent a challenge for our academic and medical institutions. Why should we spend so much time on the differential diagnosis of abdominal pain and doing a proper physical exam...when a CT could give us the answer? I'd like to mention a few of the causes responsible for this decline in clinical skills, not necessarily in order of importance. First, there is an excessive reliance on testing. This is very important because it is connected with a decline in the perceived value of clinical skills. In other words, why should we be spending so much time at the bedside trying to diagnose a heart murmur with a stethoscope when an echocardiogram can give us the answer right away? By the same token, why should we spend so much time on the differential diagnosis of abdominal pain and doing a proper physical exam when a CT could give us the answer? There is an excessive reliance on tests that is making everybody lazy. In addition to that, excessive time is spent on the computer. I am a huge fan of electronic medical records (EMRs), but we end up spending a lot of time at the computer. On the other hand, we spend very little time doing rounds at the bedside because physicians, students, and residents alike are pulled in so many different directions as a result of many competing agendas. These are a few, but certainly not the only, factors contributing to the widespread phenomenon of the decline in clinical skills. Today I'd like to present a couple of cases of improper history-taking and physical examination leading to some mishaps. Lights, Exam, Action! Dr Faustinella: During rounds at a hospital, a case of a patient was presented to me as a fever of unknown origin. This was the very last admission of the night shift. The patient was admitted to the medicine floor at around 5:30 AM and I saw her at 7:00 AM. As I entered the room, it was extremely dark, so I approached the patient, introduced myself, and asked permission to turn the lights on. Of course, the patient agreed. I saw an elderly Hispanic woman and I asked, in her language, why she came to the hospital—what was the problem? Without hesitation, the patient told me, "My leg is hurting; that's why I came to the emergency department (ED)." Of course, I proceeded with examining the patient. I removed the bed covers. What I saw were unmistakable physical findings of cellulitis, with leg erythema, edema, and tenderness to palpation. I was really taken aback. I asked my resident why he thought it was a case of fever of unknown origin when there was a clear source of fever on physical exam. His answer was, "When we examined the patient, we didn't turn the light on." Dr Vega: Was there a reason they decided not to turn the light on? Dr Faustinella: After the fact, everybody was, of course, very embarrassed. I was told that the patient got in the room very late—it was the very last admission, and they were all rushing around trying to get ready for rounds, and didn't have enough time to do a good job. So many things went wrong. Of course, I also wondered what kind of checkout the resident got from the ED and if the resident asked why the patient came to the hospital. Dr Vega: Right; there's a history issue too. Dr Faustinella: Many things went wrong, but thankfully no harm was done to the patient. The patient did well, so the delay in diagnosis and treatment did not cause any harm in this particular case. However, this is a very good example of both history-taking and physical examinations being completely forgotten. Dr Vega: That illustrates one thing that concerns me in clinical care. Of course, the patient experience is absolutely important, regardless of the setting of care. You want them to comfortable; you want them to be informed; you want to prevent pain; and you certainly don't want to cause tenderness or anxiety; you don't want that to be part of your examination. That said, sometimes it is just critical, even though it may hurt or be uncomfortable to palpate a leg with cellulitis. You need to understand the induration, calor, and fluctuance, so it's absolutely necessary. Or maybe the patient is asleep. I could see this kind of case; when the patient is tired, he just wants to sleep. He might have been examined by numerous other providers during his stay in the ED. He just wants to get it over with, but you're the admitting team; you've got the responsibility for care. You've got to turn the light on. Of course, you do so with empathy. You explain, "I wish I didn't have to do this, but it is important for your care." In retrospect, even though it may be temporarily uncomfortable to palpate the leg, I'm sure that 99% of patients would think it's better to go through that temporary discomfort to help the team get the diagnosis and get the management right versus potentially having a tragic outcome, which was avoided in this case, thankfully. Yes, Take Your Shirt Off Dr Vega: What's the other case that you're bringing to the table today? Dr Faustinella: This is a clinic case. I was in the outpatient clinic, and a 48-year-old man came in complaining of severe chest pain. Even before going into the room to examine the patient, I heard my resident order an ECG. I was on the phone with a colleague, so I decided not to intervene. I rolled my eyes a little bit because the patient should first have been examined, and even prior to that a history should have been taken, but I decided to let it go. Sure enough, the nurse came out of the patient room a few minutes later with a perfectly normal ECG, commenting on the terrible skin rash on the patient's chest wall. It was a straightforward case of herpes zoster, so an ECG was not needed. All that was needed was a history and a physical examination. Dr Vega: Thinking about patient comfort, I imagine that having ECG leads placed over a zoster rash is terribly uncomfortable. What you're seeing here is a focus on automatic algorithms without taking into account other factors. A 48-year-old certainly could have had some type of coronary syndrome, but it's still pretty rare in that age group. I also have a problem in my clinic with the automatic response. I've seen ECGs ordered before entering the room of a 22-year-old with chest pain, and it's just costochondritis or gastroesophageal reflux disease—something like that. The chief complaint in most cases is a very loose guide to where you're actually going to go on the medical interview and the physical examination. This one could have been taken care of with a brief examination and saved the patient some discomfort. I want to point out one thing: When we think about the comfort of the patient, it's important to examine the areas that need to be examined—those that are pertinent. Sometimes that means having the patient wear a gown. I try to avoid having my patients wear gowns. I try to work with their clothing. I don't think it's comfortable to sit in a gown. Some patients find it demeaning or distressing. I don't know why everybody with knee pain wears skinny jeans to the clinic, but they do, so if I can't get those jeans up past the mid-shin, I've got to get them into a gown so that I can really evaluate the knee and maybe the hip too. In this case, yes, maybe the patient was hesitant to take off his shirt, but I implore them to "take off your shirt." Go Where the Story Takes You Dr Vega: Another issue that hurts care in my practice is that some providers avoid pelvic or rectal examinations. When they're necessary, they're necessary. It's not just that the patient may be uncomfortable—I understand that—but the provider is often uncomfortable or rushed or just doesn't want to take the time. That is completely inappropriate when you have a clear indication for doing that type of examination. Go where the patient's story points for the examination. You don't need to necessarily listen to the lungs in a patient with a complaint of dysfunctional uterine bleeding, but you absolutely need to do at least a bimanual exam to evaluate the pelvic organs. Your case definitely speaks to things that I've seen and mistakes that I certainly try to avoid in my own practice. Dr Faustinella: You're absolutely right on target, particularly regarding the need for open communication. What we have to do is ask. Bring empathy into the conversation, into that interaction. All we have to do is communicate clearly. I see how patients, in the vast majority of cases, have no problem with being examined—with being looked at—and actually they're really happy that somebody's truly paying attention. All you have to do is really ask. Dr Vega: Yes. I usually take my history without a chaperone being present. Then I start by saying, "Okay, now it's time for your well-woman examination." About 80% of the time, my patients immediately start disrobing in front of me and I have to tell them, "Wait, let's get a gown—hang on, I'm going to come back." Yes, I think patients understand what's going on. They're there for a reason. Especially if they have trust, if you've established that connection, if you have that empathy and understanding of the patient, then everything goes much further. You'll be able to find the right diagnosis much sooner and get a satisfactory plan together. Dr Faustinella: The problem with oversights in history-taking and physical examination is that they might lead to a lot of negative consequences, such as delay in diagnosis and treatment with harm to the patient. Also, unnecessary testing is creating higher medical costs. In addition to these issues, there is a loss of the immense value associated with talking and listening to the patient and getting a proper history and performing an accurate physical exam. This is a value that goes beyond cost savings and any other considerations, because this is how the physician establishes a rapport of trust with a patient—a relationship that is based not only on transparency and respect, but also, and foremost, on shared humanity. Dr Vega: That's a great way to put it. Thank you, Fabrizia. Source
