The evidence-based physical exam
Short White Coat is a blog about learning to be a doctor. Posts appear here as part of White Coat Notes. Ishani Ganguli is a third-year Harvard medical student. E-mail her at shortwhitecoat@gmail.com.
Doctors rarely prescribe drugs or make treatment plans without consulting the latest research, or at least a distillation of the literature in the form of pocket-sized handbooks. But when it comes to parts of the physical exam (say, looking at the size of a patient’s jugular vein to see if she’s dehydrated), the profession has tended to rely on the techniques set long ago by the likes of Bates, author of the faux-leatherbound compendium of physical diagnosis that guided us through the second year of medical school, as well as bedside training accrued over time.
As third-years, we transition from textbooks to the original papers that inform them in all aspects of medicine. But the idea of the evidence-based exam is not only new to us, I've gathered from talking to my seniors on the team. Exam techniques undergo the same scrutiny as anti-clotting agents and appendectomies -- albeit on a smaller scale -- and doctors are starting to pay more attention, they tell me.
The Journal of the American Medical Association has a series, the Rational Clinical Examination, that analyzes these sorts of questions with titles like "Does this child have a urinary tract infection?" and "Does this patient have dementia?" How sensitive is the classic alphabetical checklist for melanoma that pinpoints skin markings that are Asymmetric with irregular Borders, multiple Colors, Diameter greater than 0.5 millimeters, and Elevated? Which angle of the nail bed is more accurate in helping you decide if a patient has clubbed fingers -- a marker for lung cancer and other diseases?
The U.S. Preventive Services Task Force rigorously reviews such studies as well in order to construct its guidelines.
With lab tests and imaging studies that are all too easy to order at the click of a mouse, this attention paid to the efficacy of the doctor’s most primitive tool has clear cost benefits. And it’s a good way to deliver the best possible patient care with limited time: know why you’re doing what you do.
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Elizabeth Cooney is a former
health reporter for the Worcester Telegram & Gazette, where she also was a
business reporter and an editor. Earlier in her career, she edited medical
books and journals at Little, Brown, and worked for Boston magazine.Boston Globe Health and Science staff:
- Gideon Gil, Health and Science Editor
- Ishani Ganguli, Short White Coat blogger
Initial physical exam instruction is at an acceptable level in current medical education, but it is one of the areas where continued followup and feedback is generally lacking for medical students. It is a testament to the reliance we have on technological reassurance in the hospital setting, which, depending on how we intend to practice medicine in the future, may or may not be a bad thing. These skills and their biostatistical significance would be especially valuable to be aware of for medicine in developing countries where laboratory tests are minimal to nonexistent, but may be stateside as well. Medical educators should decide how much they do value the teaching of physical exam skills within the evolving medical environment and with consideration of cost vs benefit.
We're back to the value of primary care. If insurers only pay physicians enough to allow 7 minutes before a patient visit becomes unprofitable, how much physical exam is going to take place? Checking for clubbed fingers - 20-30 seconds. Checking a single suspicious skin lesion - maybe a minute, if the patient undresses himself quickly and the positioning for allowing visual inspection isn't difficult. Looking at the jugular veins? Maybe another 30 seconds. Of course, the advent of the electronic medical record means a minute or two between each inspection so that the EMR can be called up, the correct screen navigated to, the appropriate boxes found and checked off, and an explanatory comment written since the boxes are insufficiently specific. Ooops. Time's up. Make another appointment so we can discuss the findings. The first 3 minutes of that one will go to calling up the record of this visit. Have a good day.
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