Can the physical examination save us from the dehumanization of medicine?

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    In last week’s NEJM, physician-author Abraham Verghese paints a disturbing picture
    of a medical world in which technology has morphed from tool to object,
    the patient relegated to a supporting role. To me, Abraham has nailed
    the diagnosis but not the treatment.

    I had the distinct pleasure of getting to know Abraham when we both served on the board of the ABIM (actually I came to know his work 15 years earlier, when I reviewed his bestselling book, My Own Country, for the NEJM). Abraham is a romantic and a traditionalist, and in last week’s New England Journal
    piece he poignantly lays out a problem he has fretted about for years:
    namely, that information technology is dehumanizing the practice of
    medicine. Describing rounds with his ward team at Stanford, his new
    academic home (he was recently recruited there from the UT-San
    Antonio), he recalls:

    When I stroked a patient’s
    palm and caused a twitch of the mentalis muscle under the chin — the
    palmomental reflex — it was as if I were performing magic. Still, the
    demands of charting in the electronic medical record (EMR), moving
    patients through the system, and respecting work-hour limits led
    residents to spend an astonishing amount of time in front of the
    monitor; the EMR was their portal to consultative teams, the pharmacy,
    the laboratory, and radiology. It was meant to serve them, but at times
    the opposite seemed true.

    Although the presence of
    such a portal doesn’t sound like a bad thing to me (it beats the hell
    out of the pager and the old Easter egg hunt looking for lab results
    and consultants’ notes), his observations about the impact of IT on the
    physician-patient relationship are salient and powerful. In
    characteristically limpid prose, he decries this “new way” of
    medicine:



    The patient is still at the center, but
    more as an icon for another entity clothed in binary garments: the
    "iPatient." … The iPatient’s blood counts and emanations are tracked
    and trended like a Dow Jones Index, and pop-up flags remind caregivers
    to feed or bleed. iPatients are handily discussed (or "card-flipped")
    in the bunker [the team’s charting room], while the real patients keep
    the beds warm and ensure that the folders bearing their names stay
    alive on the computer.

    Although Abraham advances
    the usual pragmatic arguments about unnecessary testing and missed
    diagnoses, he is clearly troubled by something much deeper, more
    fundamental, for both doctor and patient. Regarding the latter,

    Patients
    recognize how the perfunctory bedside visit, the stethoscope placement,
    through clothing, on the sternum like the blessing of a potentate’s
    scepter, differs from a skilled, hands-on exam. Rituals are about
    transformation, and when performed well, this ritual, at a minimum,
    suggests attentiveness and inspires confidence in the physician. It
    strengthens the patient–physician relationship…

    And for physicians,

    …what
    is tragic about tending to the iPatient is that it can’t begin to
    compare with the joy, excitement, intellectual pleasure, pride,
    disappointment, and lessons in humility that trainees might experience
    by learning from the real patient’s body examined at the bedside. When
    residents don’t witness the bedside-sleuth aspect of our discipline —
    its underlying romance and passion — they may come to view internal
    medicine as a trade practiced before a computer screen.

    I’ve written (here and here)
    about how computerization “de-tethers” us from the need to visit the
    radiology department, the ward, and the patient’s bedside. And I too am
    concerned that our physical exam skills may be entering a death spiral
    – underemphasized by trainees who have never learned them and
    supervisors who can no longer teach them. (Let’s be honest – many of
    our physical exams are now perfunctory performances in a Theater of the
    Absurd whose audience is comprised of coders and insurers.) That can’t
    be good.

    Yet by arguing that the physical exam will save us from
    what I’ll call “iPatient-itis,” I believe Abraham has focused on the
    wrong finding. Metaphorically, the patient does have a Boutonniere deformity, but the source of the fever is sepsis, not rheumatoid arthritis.

    Years ago – well before electronic records and CPOE – one study
    showed that internists’ fundoscopic exam skills were sufficiently poor
    (~50% error rate) that their observations were no longer useful. I’d
    wager that the same is true of most of the findings that Abraham
    nostalgically cites, such as Roth spots, subcutaneous neurofibromas,
    and the palmomental reflex. Remember that Physicians of Yore learned to
    elicit and interpret these findings during eras in which they spent 100
    hours a week in the hospital, the average patient stayed for 3 weeks
    after an MI, and they had few data to review and analyze other than
    that culled from their physical exam and a handful of rudimental lab
    and radiology studies. It seems to me that with everything today’s
    residents and students need to do and learn, the chances that we can
    revive the painstaking Oslerian physical exam are zilch, akin to the
    chance that we can resurrect the study of Latin in medical school.

    Even if we could
    create a new generation of expert physical examiners, would it be worth
    the time and trouble? I doubt it. When I was a medical student, I spent
    a couple of months at London’s Brompton Hospital, the UK’s premier lung
    disease specialty hospital. Brompton physicians lavished attention on
    the chest exam – elegantly listening for whispered pectoriloquy and
    egophany, percussing for dullness, and palpating for asymmetric chest
    excursions. Such exams often took 10 minutes. Ever the spoil-sport,
    around Minute 8, I found myself wondering why we just didn’t get a
    chest radiograph. Not because the ritual wasn’t engrossing – and yes,
    even “magical” at times – but because at some point, all of this
    elegance has to be weighed against cold-hearted considerations of accuracy, reliability, inter-observer consistency, and the cost of time.

    This
    is where my argument diverges from Abraham’s. In my zeal to bring
    physicians back into the patient’s room, I’d place 20% of the emphasis
    on performing and interpreting a good, thorough physical examination,
    and 80% on teaching and promoting superb communication skills –
    eliciting the history, describing prognosis, discussing alternative
    treatments, determining the patient’s attitudes about end of life care,
    and apologizing for medical errors, to cite but a few examples. These
    are teachable skills that will never go out of style, skills whose
    value won’t be supplanted by PET scan results and graphs of trended
    ANCA levels. And, to me at least, they highlight the patient-as-person
    and physician-as-humanist more than sticking a tuning fork on a
    forehead ever could.

    Don’t get me wrong. Like my dear friend
    Abraham, I too am terribly bothered by the “iPatient”. But Abraham sees
    the physical examination as the essential vehicle to promote a set of
    core values – the physician-patient bond, the humanism of medicine, and
    the central role of empathy – and keep our focus on real-, not on i-,
    Patients. For the most part, I don’t.

    (By the way, if somebody ever needs to stick a needle into my pleural space, please be sure they use ultrasound [performed by someone who knows what he or she is doing], not percussion, for guidance.)

    Moreover,
    by emphasizing the physical exam as the reason for leaving the “bunker”
    to visit our patients, I’m afraid we risk having that reason
    discredited. As laboratory and radiographic tests get better and
    cheaper, the physical exam may compete poorly on the playing field
    known as Evidence-Based Medicine. If our rationale for coming to the
    patient’s bedside was to test for shifting dullness and a fluid wave,
    what do we do when we discover that these are terrible tests for ascites?

    On
    one point, I’m sure that Abraham and I would speak as one: those of us
    privileged to teach the next generation of physicians must relentlessly
    promote human contact between doctors and patients. If we don’t, the
    forces of technology will gradually erode this special relationship,
    causing irreparable harm to both parties. 

    So let’s ascultate
    and palpate when it makes sense to do so. And as long as we’re doing
    these things, we might as well try to do them well.

    But I’d argue that the main reason to enter the room is to speak to the scared, ill human being in the bed.

    And, more importantly, to listen.

    ****

    A happy and healthy New Year to you and those you care about and for.

    Leave a Reply

    7 Comments on "Can the physical examination save us from the dehumanization of medicine?"


    Member
    Jun 30, 2018

    Physical examination is important, it gives insight into what is wrong with your body. Many things a normal human being can’t understand happening within themselves in their body. Like you might not understand how impure your blood is? For a situation like this doctor might ask for blood test report which will give him and the patient that what is wrong with the report. So I personally feel that it’s important to get tested.

    Guest
    Dec 22, 2009

    As a recent graduate, I thought the idea of the EMR was to automate the mundane tasks and shorten the documentation so we could get back to the patient. I think that was the promise of the industrial revolution but it instead led to our bosses pushing us harder because we now could work harder.
    Those clinical exam skills are now less important to the industry of medicine because tests are encouraged as they allow us deeper into the pocket of the healthcare complex. When the pocket can’t get any deeper or the patient says no (when they have to pay), we will once again be encouraged to use physical exam to make a diagnosis and maybe given the time to do so.
    Imagine the dreaded concept of rationing bringing back the physical exam!!!!

    Guest
    Jan 22, 2009

    I very much appreciate the dialogue about the de-humanization of health care and the implications of an IT driven physician/patient interaction. But I am here to inform you, as a patient and not a physician, “that ship has sailed!” Remember we live in a time when HMOs and other managed care organizations do not allow for lengthy interactions between patient and physician. In fact, it is well documented and accepted that physicians interrupt patients after seventeen seconds of interaction.
    We must now focus on treatment methodologies which are evidence based. Specifically, see the article published in Mayo Clinic Proceedings on August 1, 2008 which describes how KwikMed.com with its extraordinary online patient medical assessment software is safer and better than traditional medicine when treated diseases such as Erectile Dysfunction where no physical examination is required to diagnose and treat. The empirical findings at the University of Utah were that in traditional face-to-face physician/patient settings, important questions are not asked by physicians. These same questions are asked and answered 100% of the time when asked by an interactive online computer system.
    Computers can not supplant the role of the physician but there are many instances where the online interaction is better, safer, and less costly and more patient friendly than traditional medicine.

    Guest
    Jan 3, 2009

    The physical exam is actually alive and well, but it has moved down to the physical therapy department. Of course we can’t compete with ultrasound for guiding needles into pleural spaces, but we can help a lot of patients, who often report that we have examined them much more thoroughly than their doctors.
    The doctors I work with are great doctors, and the attendings actually do perform good physical exams. I’m just saying it is ironic that we PT’s, who for whatever reasons did not opt for the many years of medical school, ended up inheriting the most satisfying practices in medicine- the physical exam and the chance to spend time with our patients.

    Guest
    John Butler
    Jan 3, 2009

    In the outpatient world, I am finding that patients are more informed and better prepared for visits with the new opportunities for information access. The engaged patient has reviewed their data, graphed numbers, read up on the topic, may have initiated appropriate health behavior changes, and has well thought out ideas about treatment approaches. Share the data. Share the work. With this pre-work, the physician can listen, understand, guide. There is time for meaningful conversation. And a little more time to lay on hands is good too.

    Guest
    Jan 3, 2009

    Bob & Kate,
    I think what I am hearing is that we need to focus more on improving the quality of the patient visit/clinical encounter. Kate, even if you’re 85% is 70% for history and diagnosis today, it’s still pretty darn important. I would like to suggest that perhaps involving the patient earlier and in a more proactive manner (and yes I realize not every patient wants to be actively engaged) might enhance that history and allow for more time for a quality patient visit…perhaps a way to help reduce diagnostic errors, which are highly overlooked.

    Guest
    Kate Colwell
    Jan 2, 2009

    Bob:
    I’d echo your comments with a couple addenda:
    Most healthcare takes place outside of hospitals and the main reason we walk into the room is to speak to the scared, sometimes ill human being. I remember being taught that 85% of diagnosis is history, 10% physical exam and 5% tests. Those numbers may not reflect the current reality in a hospital, but they probably hold true for ambulatory care where we see the sad, the worried well and the chronically ill. My physical diagnosis skills are much worse than they were two decades ago. My ability to talk to people about their lives and figure out how to help them only improves with time.
    I’m delighted to carry my PDA with pharmacy information and delighted to use computers to find patient data accurately and efficiently, but most of a family doctor’s life is not making stunning new diagnoses through physical exam skills. It’s talking and caring. Those are skills that can best be taught through modeling and practice with real live human beings in distress.