Do You Still Do A Physical Exam?

The other morning, I was listening to NPR and heard an interesting story about the decreasing use of the physical examination by doctors, in favor of diagnostic testing. The story’s premise was that a rising number of physicians are ordering imaging and laboratory studies in place of performing an actual physical examination.

The Story

Here’s a short excerpt from the story that illustrates the issue:
[Dr Roman] DeSanctis [of Massachusetts General Hospital] says he recently listened to one patient's chest and heard the unmistakable sounds of abnormal fluid buildup. It turned out he had lung cancer.

"I said, 'Did Dr. So-and-so mention anything about this when he saw you?' "DeSanctis says. "And he said, 'Well, he took my blood pressure, but he didn't really examine me.' This is not an isolated case."
The story discussed the mounting pressures on doctors to complete a patient visit in ever-decreasing time allotments, as well as an over-reliance on advanced testing, leading physicians away from the physical exam.  This started me thinking, of course, about podiatry. 

Are we still performing physical exams?  Are we any different from the rest of the medical community?  Should we rely on technology over our physical exam?

Technology vs Hands On Skill?

We are moving towards a greater reliance on technology, especially when we compare modern physicians with those of the past.  Dr. William Osler (of Osler node fame) was renowned for his ability to diagnose patients’ illnesses by physical examination alone.  Remember, in Osler’s time (early 1900’s), the only technology available was the radiograph, x-rays having been newly discovered in 1895.  These doctors relied on the basic exam techniques of auscultation, palpation, percussion, and inspection to diagnose the same diseases we identify today using ultrasound, MRI, CT, and scintigraphy.  Could you imagine tasting someone’s urine for sweetness to diagnose diabetes or observing a patient’s back for an aneurysmal tumor?  I would argue MRI has become the standard imaging technique for almost all soft tissue tumors.  Is that better care or laziness on our part? 

How We Do It in Podiatry

On the other hand, I firmly believe we in podiatry are affected by this trend  to a much lesser extent than our general medical colleagues.  This is due at least in part to our focus on one body region that is more accessible to our examining hands. Although it’s true that 90% of diagnoses are made by history alone, we still rely on the physical exam to not only confirm the diagnosis but to understand the qualitative nature of the specific diagnosis.  For example, it’s easy to diagnose hallux valgus by history of 1st MTP joint pain, and a quick inspection of that part of the foot will demonstrate the overall pathology.  However, in order to appreciate the specifics of the deformity (apex, arthritic changes, flexibility, reducibility, range of motion, contribution of hindfoot mechanics, equinus, etc.), an in-depth biomechanical examination is necessary.  This requires a comprehensive understanding of the podiatric physical examination.  Similarly, if I suspect PAD with claudication, I’m not going to jump immediately to an MRA.  First, I’ll correlate the patient’s history with physical exam findings to determine the appropriate next step.  I think most podiatrists would follow a similar protocol.

We also have a more realistic understanding of the limitations of our diagnostic tests.  Take the probe-to-bone test.  Initially, after the original Grayson study1, everyone thought probing to bone in any patient clinched the diagnosis of osteomyelitis.  We then learned, after research by Lavery, et al.2, that a finer appreciation for the limitations of this test are necessary.  We now understand that the test is more useful in its negative predictive value, especially in patients without significant infections.  A similar argument may be made for the other advanced imaging modalities.  For example, MRI does not always guarantee an ability to differentiate osteomyelitis from Charcot arthropathy.  We constantly reiterate to our student doctors and residents that they must correlate the history, physical examination, and any subsequent imaging or labs.  As such, our reliance on advanced testing, though increasing, is at a much more realistic level.

Education Is the Key

The key to continuing to rely primarily on our ears, eyes, and hands is education.  We must teach our future podiatrists correctly.  Sounds simple in theory.  Just show someone how to palpate pulses or perform range of motion testing, right?  It's not quite so simple.  We take for granted the ease and speed at which we evaluate our patients – all of which are the benefit of good training.  In reality, there is a spectrum of competency from one student to the next that needs to be constantly evaluated and improved.

Research shows that medical training programs could be doing a better job teaching physical examination methods and evaluating the performance of those skills.  Researchers in one study3 found, for example, that internal medicine and family practice residents who were asked to listen to 12 heart sounds and identify those sounds were accurate on average 20% of the time.  Was the deficiency due to residents’ lack of motivation?  No.  It was lack of appropriate education and assessment.  It was their teachers’ fault.

This trend away from the physical exam has many factors, including time, availability, and ease of use.  However, the best way to prevent this from becoming any more pervasive – indeed reversing the trend – is to impart those important skills onto our trainees as much as possible.  For those of you training students and residents, make certain your trainees are performing all of their required skills correctly.  Don’t take them at their word that they can perform a certain skill.  Watch them obtain histories and physicals.  Make sure your trainees can demonstrate directly, in front of you, the ability to obtain an appropriate and complete history, correlate a comprehensive physical examination with that history, and utilize advanced testing only when appropriate. 

It’s up to us to emphasize the importance of the physical examination or our future colleagues will be unable to do more than order the CT scan or MRI.  I know that’s not the type of doctor any of us want to create.  Best wishes.

Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum. Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

References

GET IN ON THE DISCUSSION There are several eTalks topics taking place right now on PRESENT Podiatry. Get in on the discussion, or start one of your own.

Get a steady stream of all the NEW PRESENT Podiatry eLearning by becoming our Facebook Fan. Effective eLearning and a Colleague Network await you.

Grand Sponsor Major Sponsors