I remember my first visit home at the end of my second year of medical school. I'd just received my black doctor's bag loaded with medical equipment. Like a 16 year old with a new driver's license who begs to do the very errands she'll soon groan about, I went around my parents' living room and took everyone's blood pressure, looked in their ears and throats--and then made my "rounds" again.
While I never got tired of doing physical exams, they did, of course, lose some of that initial thrill.
But now that parts of the exam are being outsourced to assistants, I miss them. And I find myself feeling not so different than I did on that spring day so long ago when I asked, "Please, can I take your blood pressure, please?"
Various tasks previously done by physicians are now assigned to nurse practitioners, physicians' assistants, medical assistants, and other "physician extenders." These tasks range from the simple taking of blood pressures and giving vaccines to the more complex: annual physicals, hospital admissions, and pre-operative medical clearances. The Affordable Care Act (aka "Obamacare") mandates increased training of such extenders. The Patient Centered Medical Home, a team-based model of medical care in which the physician is one of many primary caregivers, is considered the future of medicine.
There are good reasons for a team approach, including current and projected physician shortages, especially in primary care, and pressures on physicians to crowd many patients onto their schedules because of low Medicare and other reimbursements. Many argue, reasonably, that some jobs must be off-loaded just to give doctors more time to be doctors--to diagnose patients' problems, formulate treatment plans, and offer counseling about how to prevent illness.
But I sometimes worry that however well-intentioned or more efficient this meting out of roles may be, we could be losing something important--even if difficult to quantitate--in the process.
Take for example...blood pressures. Measuring blood pressure, especially with an electronic cuff, requires little training. But it offers an opportunity to touch a patient, one I'm not sure we doctors should be so quick to abandon. Many times I have seen a patient for a consultation--say, to discuss birth control or assisted living or an imminent divorce--and capped the visit by taking the patient's blood pressure and listening to their heart and lungs.
In over 20 years in practice I have never yet had a patient ask me why I was examining them when their problem wasn't "physical." Touching a patient is part of paying attention to them, of caring for them--and always has been.
Abraham Verghese, physician and author, has written about the lost art of the physical exam. He claims that patients feel better cared for when properly examined, and that a skillfully performed exam aids diagnosis and saves money on x-rays and other testing.
My own experience is that the physical exam has another, harder to define but no less important benefit: It makes me feel more connected and attuned to the patient.
Recently, my practice adopted the common procedure of having an assistant take the patient's blood pressure after escorting him or her into an exam room.
But I keep forgetting about the new procedure, and start my exam as I have always done--by taking the patient's blood pressure.
Last week, as I wrapped the cuff around her arm, a patient said: "Oh, someone already did that."
I said, "I know, but somehow I can't stop taking blood pressures myself."
The patient, a thoughtful young woman, asked, "So it's like a ritual for you? Like breathing before yoga?"
And I answered, "Exactly!"
The author is solely responsible for the content.