Technology displacing physical exams
By Sandra G. Boodman
Doctors at a Northern California hospital, concerned that a 40-year-old woman with sky-high blood pressure and confusion might have a blood clot, order a CT scan of her lungs. To their surprise, the scan reveals not a clot but large cancers in both breasts that have spread throughout her body.
Had they done a simple physical exam of the woman's chest, they would have been able to feel the tumors. So would the doctors who saw her during several hospitalizations over the previous two years, when the cancer might have been more easily treated.
A middle-aged man admitted to a Seattle emergency room for the third time in six weeks displays the classic signs of liver cirrhosis for which he has been repeatedly treated, including swollen legs and a distended abdomen.
But a veteran doctor spots a telltale indicator of a different disease: rapid inward pulsations just beneath the man's right ear. The patient's problem is not his liver but his heart: he has constrictive pericarditis, a serious condition that requires surgery.
Both cases reflect a phenomenon that some prominent medical educators say has become increasingly commonplace as medicine becomes more technology-driven: the waning ability of doctors to use a physical exam to make an accurate diagnosis. Information gleaned from inspecting blood vessels at the back of the eye, observing a patient's walk, feeling the liver or checking fingernails can provide valuable clues to underlying diseases or incipient problems, they say.
[See also: EHR rethink may reduce unneeded tests.]
But over the past few decades the physical diagnosis skills that were once the cornerstone of doctoring have withered, supplanted by a dizzying array of sophisticated, expensive tests.
"A lot of people downplay the physical exam and [wrongly] say it's fluff," said Salvatore Mangione, associate director of the internal medicine residency at Philadelphia's Jefferson Medical College and director of its physical diagnosis curriculum.
In a 2012 article in the Cleveland Clinic Journal of Medicine, Mangione wrote that he has seen "many cases in which technology, unguided by bedside skills, took physicians down a path where tests begot tests and where, at the end, there was usually a surgeon, and often a lawyer. Sometimes even an undertaker."
To address the problem, programs to revive and teach physical diagnosis -- also known as bedside medicine -- are underway at some medical schools, including Stanford, Jefferson and Johns Hopkins. The programs are predicated on a belief that these skills are an essential adjunct to technology and can boost diagnostic accuracy, curb unnecessary and expensive testing and foster a greater connection between patients and doctors, many of whom spend increasing amounts of their day staring at their computers rather than looking at the patients they are treating.
At Hopkins, a Web-based program called Murmurlab.org seeks to improve young doctors' ability to use a stethoscope -- a tricky skill that studies have shown is lacking - to distinguish serious cardiac problems from far more common benign heart murmurs.
The goal is to reduce unnecessary and costly echocardiograms.
"There are two reasons it remains crucial to do this [physical diagnosis] at least as well as doctors did 100 years ago," said internist and best-selling author Abraham Verghese, senior associate chairman of Stanford's program on the theory and practice of medicine. Verghese was instrumental in creating the six-year-old Stanford Medicine 25 program: 25 physical exam skills that students are required to learn, demonstrate and teach. These include assessing enlarged lymph nodes, measuring ankle reflexes and performing a knee exam.
"We can pick off the low-hanging fruit - the obvious diagnosis that one can miss at great cost to the patient," such as the woman whose metastatic breast cancer was repeatedly missed, Verghese said. In his view, the physical exam also represents an "important transactional moment" between doctor and patient - a laying-on of hands that helps foster trust. An increasingly common complaint from patients, he said, is that "the doctor never touched me."
Overreliance on technology, he said, has produced perverse results. "If you come to our hospital missing a finger," he quipped, "no one will believe you until we get a CT scan, an MRI and an orthopedic consult."
Differentiating heart murmurs
But some experts are skeptical that reviving the physical exam is the best approach in the 21st century. Robert Wachter, former chairman of the American Board of Internal Medicine, said he shares Verghese's concerns about declining clinical skills. But Wachter said he isn't sure that "restoring the physical exam of yore" is a solution.
"Taking time and energy to train doctors in the physical exam may be less valuable than teaching them how to communicate or to analyze . . . data," said Wachter, associate chairman of medicine at the University of California at San Francisco. "You've got to make some choices."
There is general agreement that the technological explosion that began in the 1980s led to the decline of bedside skills.
Insurance that pays for tests but gives short shrift to a careful and time-consuming history and physical exam accelerated the trend, as has the growing paperwork burden doctors face. The generation of influential mentors who taught physical diagnosis has largely retired. Even bedside rounds - where such knowledge was often imparted to impressionable neophyte physicians -- are mostly a thing of the past, migrating from a patient's hospital bed to a conference room down the hall where test results and the chart -- not the actual patient -- are examined.
Too often, physical exam skills are dismissed as inferior relics of the past when compared with "the glitter and perceived objectiveness of modern technology," said Steven McGee, a professor of medicine at the University of Washington and the author of a recent textbook on evidence-based physical diagnosis.
McGee said that studies have found that physical exam findings can be as accurate as their technological counterparts. Case in point: A pair of studies involving 185 acutely dizzy patients found that the presence of certain abnormal eye movements were more accurate than an initial MRI scan in distinguishing a serious stroke from a benign inner ear problem.