Reexamining the Physical Exam
By Susan Carr | Senior Writer, ImproveDx
The physical examination, once the cornerstone of diagnosis, has fallen on hard times. Advanced testing and imaging exams, readily available in most settings, often take precedence, while physicians are pressed to find enough time to do a thorough exam. The electronic health record competes with the patient for attention. And physicians note that the practice of medicine has become more technological and increasingly disembodied. These changes have devalued the physical exam in practice and medical education, in a vicious circle where technical skills play second fiddle to technology and are likely to atrophy.1-4
Responses to this trend include reflections on the exam’s value as a diagnostic tool.5 In a study of patients admitted via the emergency department, 80% were diagnosed correctly based on history, physical examination, and basic laboratory testing alone.6 Some physicians have observed that clinicians with solid bedside skills are less dependent on and “…make better use of diagnostic tests and order fewer unnecessary tests.”5(p1385) Regarding the value of the physical exam, Mark L. Graber, MD, co-founder and chief medical officer of the Society to Improve Diagnosis in Medicine, emphasizes:
Besides being absolutely critical in pointing to the correct diagnosis, it is an irreplaceable element of establishing an effective clinical relationship. (written communication, January 2020)
Physicians are eloquent about the ritual of human touch in medicine and the uniqueness of the physical exam in human encounters.7,8 And while there is reverence for the ritual and the information and connection it can provide, the physical exam is also drawing attention, especially in outpatient settings, as an encounter prone to error.9
The worst exam is no exam at all
In a qualitative survey of physicians across all specialties, researchers found the most common defect in physical exams was simply not performing one at all.10 The survey (n=63) asked for “vignettes of known…oversights”—the purpose was to gather stories, not to measure statistical prevalence. However, among the oversights reported, 63% were attributed to no physical exam having been performed. In 14%, the information gathered by physical exam was misinterpreted; 11% included cases of missing or not seeking the relevant sign; and in 12% the deficiencies classified as “other.” The authors observed that physicians appear to work in an “ignorance trap,”10(p1324) rarely receiving feedback about oversights related to physical exams. They also point out that electronic medical records may overstate the number of physical exams performed and that exam deficiencies are not easy to study and remain largely unexamined.
Improving the performance of physical examinations
In response to calls to improve the training, practice, and assessment of physical exams, individuals and organizations offer new resources and guidance.
Noting that “In modern healthcare, the clinical consultation is almost completely overlooked and ignored,”3(p503) UK physician Gordon Caldwell calls out circumstances that contribute to problems and poor outcomes. He suggests improving the quality of the encounter, which should usually include a physical exam, by asking that:
- Both the patient (to the best of their abilities) and clinician be prepared for the visit.
- The clinician knows the patient as a person (not just as a patient).
- The environment be as free of distractions, such as noise and interruptions, as possible.
- The clinician be rested and “refreshed.”
- There be sufficient time allowed for the consultation.
- The patient’s confidentiality and dignity be maintained.
- The patient be encouraged to bring someone along for support.3
Dr Caldwell’s quality indicators set the stage for improved clinical exams. Other guidance targets improving the physician’s actions, the role of the exam in broader practice, and the need for feedback and assessment.
A group of physicians from the United States, England, and Scotland (all founders and board members of the Society of Bedside Medicine,) recently published a guide to “reinvigorating the clinical examination for the 21st century.”4 They advocate adopting the following six strategies in practice and for teaching medical trainees:
- Be present with the patient.
- Practice an evidence-based approach to the physical exam.
- Create opportunities for intentional practice of the physical exam.
- Recognize the power of the physical examination beyond diagnosis.
- Use point‐of‐care technology to aid in diagnosis and reinforce skills.
- Seek and provide specific feedback on physical examination skills.4(p907)
The evidence-based approach in strategy #2 includes the “hypothesis-driven physical examination,”11 in which physicians use pre-test probabilities to tailor physical exams for patients, much as they would when ordering labs and imaging tests.
“Intentional practice” in strategy #3 includes opportunities for training, such as Stanford’s Five-Minute Moment, a template for teaching exam skills at the bedside by combining a brief narrative with a demonstration of the physical maneuver, interpretation, and common caveats and errors.12 The Five-Minute Moment is one component of the Stanford Medicine 25, a collection of live and virtual training opportunities focused on a core and growing set of common diseases and conditions. Led by Abraham Verghese, MD, Stanford Medicine 25 aims to help students and clinicians learn and master bedside skills. The project’s website explains:
In observing students and residents perform physical diagnosis maneuvers at the bedside, we observe that though they know the theory, their technique may prevent them from eliciting the sign reliably.
Much of medical error can be avoided if we take the time to lay hands on the patient and find that clue or obvious exam sign. We teach to always exam and make sure to never miss the low hanging fruit!
Other resources for training include Johns Hopkins’ “case-oriented report and examination skills”13 and activities in the Clinical Skills Center at the American College of Physicians’ annual internal medicine meeting.
The expanding use of point-of-care ultrasound (POCUS) has revitalized the physical examination in recent years. Early applications have focused on using POCUS to better diagnose abdominal and thoracic conditions, but applications to aid in the examination of every organ system are rapidly emerging.
Using sensor technology to improve the physical exam
Part of the “ignorance trap” for clinicians is a lack of useful feedback about what kind of touch is most effective. The actual mechanism or “art and science” of touch—haptics—is only one element of the physical exam, but it is crucial and, until recently, unexamined.
Carla Pugh, MD, PhD, a surgeon and educator who refers to herself as a “physical exam evangelist,” points out a disconnect in training physicians in manual skills:
How do you master a body of knowledge when some of the most important things you’re supposed to know can’t be learned in a lecture or a book?14
And when manual skills are not prioritized in education, assessment also suffers. Dr Pugh laments that medicine continues to rely solely on the text-based board examination. A number of methods are used to assess competency in hands-on skills,2 but Dr Pugh finds that medicine lacks appropriate and reliable tests of haptics as used in diagnosis and treatment.
We don’t have a sure-fire way of teaching [haptics], a way of measuring it and therefore we don’t have a way of assuring competency.14
Dr Pugh is director of the Technology Enabled Clinical Improvement Center (TECIC) at Stanford Medicine. She keynoted the Diagnostic Error in Medicine 12th Annual International Conference (DEM2019) with a talk titled, “The Modern Physical Exam: How Can We Make It Better?”15 She is leading efforts at TECIC to improve care by using sensor technology and data-driven metrics to improve provider performance of manual skills.
In a 2018 interview, she described the moment when she recognized a gap in her own surgical training:
Before I could operate on a tumor, I needed to know how densely it was attached. A CT scan couldn't tell me — the only way I'd know was through my hands. I realized I wouldn't truly learn how to diagnose with my hands just by watching my instructors, and I wanted to find a better way.16(np)
Dr Pugh, who now holds three patents, addressed that gap by developing a way to use sensors to understand and evaluate how physicians use their hands while examining patients.
In her research, as clinicians perform, for example, a simulated breast exam, sensor-enabled mannequins generate waveforms and over time create a signature profile for accurate exams. To test the technology, Dr Pugh and her research partners recruited physicians attending clinical meetings of the American Society of Breast Surgeons, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists in 2013 and 2014. More than 500 physicians participated by searching for a suspected lesion on sensor-enabled breast models. In addition to accuracy data, the models recorded the force of the manual palpation of the breast, and Dr Pugh was able to show that increased pressure is associated with better accuracy. She found that approximately 15% of experienced clinicians did not apply enough force to find the lesion. The team pointed out in a letter to the New England Journal of Medicine that:
Since variations in force cannot be reliably measured by means of human observation, our findings underscore the potential for sensor technology to add value to existing, observation-based assessments of clinical performance.17(p785)
Dr Pugh also gathered data on the relative accuracy of different palpation techniques in breast exams and found that clinicians who use a common technique she calls “piano fingers” to search the breast are four times less likely to find a lesion compared to their colleagues.
Responding to that data presented at DEM, a woman in the audience asked Dr Pugh if she thought patients should be prepared to ask their physicians to use the most effective techniques in breast exams. Dr Pugh chuckled and replied:
She’s trying to start a revolution! I like that! I think we should all be informed and receptive. If the patient knows about it before you [the doctor] do, I hope she’ll say something and that you’ll be receptive.
To a question about women learning the most effective technique for self-breast exam, Dr Pugh said she and her team have started talking to women’s wellness meetings and have found the response to be “absolutely overwhelming.” Women want to learn the best technique and to learn by feeling through simulation what they are searching for in self-exam.
Dr Pugh feels it is crucial that physicians receive the feedback her technology provides. For now, the research is limited and early, but Dr Pugh feels that opportunities to understand the haptics of manual maneuvers, to adjust technique for personal preference, and improve effectiveness are limitless. She sees a day in the future when this approach could be used routinely as part of ongoing, formative assessment for quality improvement. The information is potentially disruptive, and Dr Pugh feels strongly it should not be used against clinicians. The emphasis must be on enhancing human performance for the physical exam, not on relinquishing control to technology.
Thank you to our reviewers: Jeannine Cyr Gluck, MLS; Mark L. Graber, MD; and Lorri Zipperer, MA.
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