The Importance of the Physical Exam

A conversation with Abraham Verghese, MD, the Linda R. Meier and Joan F. Lane Provostial Professor; and John Ioannidis, MD, a C.F. Rehnborg Chair in Disease Prevention and Professor of Medicine.

How has the physical exam changed in medicine?
Verghese: Physicians once relied on the five senses to diagnose patients. They used sight, touch, sound and smell to assess health and identify illness. Today, medical technologies are often a doctor’s first diagnostic tool.

What is the importance of the physical exam?
Verghese: The simple yet essential process of conducting the physical exam is "low hanging fruit." With the ascendance of technology there began to be less and less emphasis on what is obviously on the body that you can easily diagnose. We often spend so much time with that entity in the computer, what I call the ‘iPatient, that the real patient in the bed is often left wondering, 'Where is everybody? What are they doing?' I sense that we’re spending very little time at the bedside.

Many of us recognized that there was a gap between what the medical record claimed was done on the patient, and the actual execution of the task. It reflects an increasing dependence on technology, and only paying lip service to the actual examination of the patient. It would be a shame for us to have reached this place where the only way we can make certain diagnoses is by ordering expensive and fancy tests when the diagnosis was really there all along for us to see.

What are the consequences of lapses in the physical exams?
Verghese: Stories of shocking medical errors that occur because doctors miss something during a physical exam, or forget to examine a patient at all, are common. Every physician knows them. I think of it as my worst nightmare, that a patient will slip through my grasp with a diagnosable or treatable condition.

Ioannidis: Physical examination inadequacies are a preventable source of medical error, and adverse events are caused mostly by failure to perform this relevant examination. Little has been done to quantify this type of medical error. In a first step toward creating a data-based measurement of medical errors due to inadequacies in the physical exam, Dr. Verghese and I published a study in the American Journal of Medicine, which reports on a collection of 208 such occurrences and their consequences. Together with researchers from UCSF, Stanford and Tufts, we collected the incidents from responses to surveys sent to 5,000 physicians asking for first-hand stories of such medical errors. The cause of the oversights in the 208 responses was most often a failure to perform the physical examination at all — in 63 percent of the cases. Other times, errors were caused by misinterpreting or overlooking physical signs.

The consequences of these mostly preventable mistakes varied from missed or delayed diagnoses in 65 percent of patients, to incorrect diagnosis in 27 percent or unnecessary treatment in 18 percent. We are talking about missing things that are very common, a mass, or a sore or a heart murmur or something in the lungs, that leads you down the wrong path. This is something that happens everyday, and it’s something that could be corrected to a good extent.

Is the practice of physical exams being lost in medicine today?
Ioannidis: I doubt that anyone will come out and say we don’t need to have physical exams, but in real life, this is something that unfortunately gets lost. Doctors think that it’s okay to skip or rush through the physical exam, that the X-ray or the CAT scan will tell the story. But in reality, that is just not the case.

The study’s list of 208 medical errors reveals many such instances. For example, one physician missed a rash indicating shingles in a patient who presented with chest pain, which led to an unnecessary coronary angiogram before the correct diagnosis was made. Another physician missed a scar for gastric bypass surgery, which would have explained the patient’s malnutrition, weight loss and a rare vitamin deficiency, delaying treatment. What we see is that these are mistakes and errors that any physician can make. In many cases, it wasn’t any fancy thinking; someone just didn’t look.

To learn more, go to: http://www.amjmed.com/article/S0002-9343%2815%2900549-5/abstract.