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The Physical Exam Provides More Than Emotional Value

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This month and next, fresh batches of bright and eager first-year medical students will be strolling into their classrooms and lecture halls. They'll be diverse, smart and, hopefully, as idealistic, optimistic and altruistic as we want our future doctors to be.

These baby-docs, quick at their keyboards, will be asked to digest unprecedented amounts of information. Along with the hard new sciences - modern genetics, cell biology, immunology and molecular mechanisms of disease, heaped onto the old, battered stuff of anatomy, microbiology, pharmacology and stats - taken in just the first two years, no less, they'll face assignments in medical ethics, communication and the costs of health care, which some now suggest is essential to the curriculum.

What I wonder is how physical examination, typically considered an art, will fit into the ever-evolving medical school program. The stethoscope, an early 19th Century invention, remains a powerful symbol in medicine today. It's no accident that students, resident physicians and some doctors on TV wear these prominently draped around their necks. I'm afraid that many real, practicing doctors don't exactly know what to do with those old-fashioned tools.

Recently, Dr. Danielle Ofri considered the value of the doctor's touch in the New York Times. In that essay she describes an encounter with a patient during which, toward the end of the appointment and almost as an afterthought, she pulled out her stethoscope and performed a physical exam in a cursory but thorough manner. She writes that the laying-on of hands is inherently humanizing. "For a doctor-patient relationship to have meaning beyond that of a business interaction, there needs to be trust" she says. "One of the most basic ways to establish trust is to touch."

She's right. I know this from my recent experiences as a patient. When one of my doctors examines me, physically, I feel better and safer, somehow. If I visit a doctor and she fails to examine me, I worry that she's missed something or, what's worse, that she doesn't care. One of the biggest limitations of telemedicine, which may by necessity in the future provide a disproportionate amount of care to people in rural districts, is the absence of real contact.

Feelings aside -- what's also true, in a practical and bottom-line sort of way, is that a good physical exam can help doctors figure out what's wrong. If physicians were more confident, better trained and practiced in their capacity to make diagnoses by physical exam, we could skip the expense and toxicity of countless x-rays, CT scans and other tests.

It happens I know something about physical exams. Early in my years on the junior faculty at Cornell, around 1994, I was assigned to teach physical examination to second-year students for each of two consecutive spring semesters. To prepare for those weekly sessions, I re-read my then-old copy of Bates' Guide to Physical Examination.

Together, my students and I listened to normal and abnormal heart sounds. We looked in each others' eyes with ophthalmoscopes. We checked patients with lymphadenopathy (swollen glands), big livers and palpable spleens. We listened and described course and fine rales on pneumatics' lung exams, and held arthritic joints with swan-like deformities characteristic of rheumatoid arthritis. We examined patients' petechiae, purpura, ecchymoses and more, and discussed the differences among those findings and what those might signify. All of this we did without CT scanners, echo machines or other complex devices.

I know also that a physical examination can be life-saving. Once, when I was in the hospital as a child and had unexplained fevers after surgery, it seemed for a while that no one could figure out what was wrong. I was terrified. The surgical team consulted with an infectious disease specialist, who ordered a battery of unpleasant tests when my dad - a physician - noticed that one of my legs was more swollen than the other. He realized, based on my physical exam, that I might have a blood clot. It turned out he was right.

I agree that the physical exam is humanizing, so much that later on in my career, when I routinely donned space suit-like gowns and masks to examine patients during rounds on the leukemia and bone marrow transplant services at our hospital, I became frustrated by those barriers and by the very lack of touch which, I think, really helps patients to heal.

As in all aspects of medicine, experience and training enhance a doctor's ability to provide good care. When done properly by a practitioner with clean hands, the physical exam's value extends beyond the humanistic side of medicine - it's a handy, diagnostic tool.

Recently I wrote on medical education and going back to basics. The physical exam should be included, for sure.

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