Never Underestimate the Power of a Physical Exam
Like most physicians, I feel extremely rushed during the course of my workday. And like the vast majority of us, the “if you didn’t document it, it didn’t happen” mantra has been beaten into me. So time-consuming is this process, I often feel enslaved to the quantitative.
As a result, it’s tempting to rush through physical exams, and to assume that if there’s anything “really bad” going on with the patient, some lab test or imaging study will eventually uncover it. Just swoop in, listen to the anterior chest wall, ask if there’s any new pain, and dash off to the next hospital bed. Then, construct a five-page progress note in the EMR describing the encounter, assessment, and plan of care.
Revisiting the physical exam in a more focused way certainly has its place in follow-up care, but I strongly encourage us all to reconsider any urge to skimp on that initial exam. There’s just too much that can be missed as we scurry about. Here, are some examples of things I discovered when I applied the careful, fine-toothed comb approach to a first-time physical:
- A pulsatile abdominal mass in a woman being worked up for dizziness
- New slurred speech in an edentulous gentleman with poorly controlled hypertension
- A stump abscess in a two-year-old leg amputation
- A bullet lodged in the scrotum
- Countless stage one sacral decubitus and heel ulcers
- Rashes that were bothering the patient for years but had not previously been addressed and cured
- Early cellulitis from IV site
- Deep venous thrombosis of the calf
- New onset atrial fibrillation
- Peripheral neuropathies of various kinds
- Lateral medullary syndrome
- Surgical scars of all stripes — indicating previous pathology and missing organs of varying importance
- Normal pressure hydrocephalus in a patient who had been operated on for spinal stenosis/scoliosis
- Parkinson’s Disease in a patient with a fractured hip
- Shingles in a person with eye pain
- Aortic stenosis in a woman with dizziness
- Pleural effusions in a man complaining of anxiety
Oftentimes, of course, I don’t find anything new or exciting. Certainly nothing that is not already a part of the patient’s medical record. But a curious thing happened to me the other day that made me reflect on the importance of the physical exam: I had performed a careful review of a complex patient’s history and current physical presentation, discussing with him every scar and “abnormality” I discovered, his aging body having revealed more than he had at first remembered to say. As our exam drew to a close, he reached out and offered me a fist-bump.
It was charming and unexpected. But it also was something more — it made me realize the true importance of the thorough exam. Through this process, I had gotten to know my patient. I had earned his trust, and we had built the kind of therapeutic relationship upon which good healthcare is based. No EMR documentation effort was worth missing out on this interaction.
You may not uncover a new diagnosis on each physical exam, but you can gain something just as important: the confidence and respect of the patient.
Val Jones, M.D., is an award-winning blogger and the founder and CEO of Better Health, LLC, where this post also appears. Most recently she was the Senior Medical Director of Revolution Health and the founding editor of the online Medscape Journal of Medicine’s peer-reviewed e-section, Clinical Nutrition & Obesity. Frequently quoted in outlets such as the Wall Street Journal and the LA Times; she is also an editor of the Science Based Medicine blog; a contributor to The Health Care Blog, The Doctor Blog, and ABC News Channel 8 in Washington, DC; and a National Press Club member. Dr. Jones is a graduate of Columbia University College of Physicians and Surgeons and is board certified in Physical Medicine and Rehabilitation.