The physical examination is a time-honored tool for physicians for the evaluation and care of patients. For centuries, physicians relied on observation, palpation, percussion, and auscultation to confirm diagnostic hypotheses generated by taking a careful history or to detect problems before symptoms develop. However, the examination has recently been questioned in terms of importance, value, and accuracy. During the past 4 decades, the proliferation of sophisticated (and expensive) laboratory and imaging tests has threatened to marginalize the physical examination. Faith Fitzgerald argued in a 1990 review titled “Physical Diagnosis Versus Modern Technology,” that because of diminishing financial resources, time pressures, and physician need for certainty, “it is imperative to scrupulously reexamine the role of the physical examination in modern diagnosis.” She concluded that “the best interest of patients lies in a judicious combination of careful history and physical examination and directed laboratory studies.” A 1992 Annals of Internal Medicine editorial titled “Has Medicine Outgrown Physical Diagnosis?” concluded that physicians and society need to be willing to use simpler methods of diagnosis where the marginal gain in certainty provided by technology is slim. During the more than 2 decades since these arguments appeared in the literature, technology and ready access to the results of studies continue to advance, seemingly threatening the utility of the low-tech physical examination.
A competently-performed physician examination would certainly be considered a simpler method of diagnosis, but many time-honored techniques may not be accurate or consistently reproducible.[3-7] Phoon posed the provocative question, “Must doctors still examine patients?” and provided arguments for and against the physical examination but finally concluded that it would continue to be important in the practice of medicine. Abraham Verghese, a strong and eloquent proponent for the physical examination and for insisting that our trainees be certified in its performance, invoked the image of the patient as an icon on a computer screen because evaluation of laboratory tests, imaging, and various other tests are done essentially remote from patients and as a consequence, the physical examination is in danger of being deemed irrelevant.
Most physicians argue for continuing to examine patients, but what do patients think about the physical examination? If patients do not value the physical examination, then perhaps precious physician time would be better spent in other ways. In this issue, Kadakia et al describe a relatively simple yet elegant study of patient perceptions of the physical examination. The investigators should be congratulated for taking on an extremely important question for physicians who care for patients with advanced disease. Patients in the study had a range of advanced malignancies and might be expected to be less interested in being examined because of frequent physician encounters, fear of discomfort, or a sense that the exam would not add much for medical decision-making. Remarkably, only one patient in the study cohort of 148 patients rated the physical examination as a negative experience and the majority of patients felt it was highly positive.
Study patients were equally divided about whether the exam was more useful for medical management (pragmatic reasons) or for demonstrating that the doctor cared (symbolic reasons). Pragmatic reasons for examination, particularly for patients with advanced malignancy include determining a new cause of symptoms, assessing the status of the malignancy, and monitoring or guiding therapies. Symbolic reasons for examination include demonstrating interest in the patient's problem, validating concerns, and establishing an empathetic connection with the patient. A number of authors have argued specifically for the benefit of touch in the course of examination.[13-15] Pragmatic and symbolic motivations for examination are not mutually exclusive. Either motivation (pragmatic or symbolic) should be sufficient to continue examining even the most ill patients, provided the examination is perceived by patients to be beneficial as it clearly was in the study by Kadakia et al.
As the authors point out, the study yields additional interesting observations. Patients with higher depression scores or higher burden of spiritual pain viewed the physical examination less positively. These patients potentially benefit more from counseling and less from physical interventions. Experienced clinicians likely recognize this situation and might dispense with the examination during these encounters, although it would be important to discuss the omission of the exam explicitly in order to be sure patient expectations are being met. Studies in primary care practices suggest that physical examination is expected during patient encounters and if the expectation is unmet, patients are less satisfied.[12, 16, 17] The majority of patients in the current study also expected to be examined during visits with their physicians. For health systems that are increasingly evaluated using patient satisfaction scores and whose financial reimbursement will be partially dependent on these scores, this study reinforces the need to consistently examine patients.
The study also found that nonwhite patients viewed the physical examination more favorably than did their white counterparts. This finding was driven primarily by the patients' sense that the “exam shows that the doctor cares for me.” It would be interesting to know if this finding applies to patients with other or less advanced illnesses. Patients with less education rated the physical examination higher than patients with college education or more. It would be useful to better understand the influence of race and education on perception of the examination in order to better tailor patient physician encounters.
Another interesting finding is the relationship of age to positive perception of the physical examination (odds ratio of 1.07 for every year of age). The median age of patients in the study was 57 years, with a range of 23 to 83 years. Older patients may simply have grown up in an era when physicians relied more on the examination, and therefore these patients expect that each time they visit their health care provider, they will be examined. Younger patients who are more accustomed to social interactions via texting and other electronic media would have been underrepresented in the Kadakia et al study. These patients may have different expectations regarding hands-on contact. They may be more accepting of physicians using approaches to diagnosis that do not include the physical examination, but rather rely on electronic systems that provide detailed imaging and laboratory results. Younger patients or those who spent a substantial part of their time interacting socially or professionally via virtual means would be interesting groups to survey about perceived utility of the physical examination.
Patient subgroups in this study are too small to allow confident assertion that a specific patient group is most likely to expect and appreciate physical examination during an encounter. However, one could potentially extrapolate that older, nonwhite patients with less than college education and without significant depression or spiritual pain would be the most likely to expect and appreciate physical examination during visits.
The investigators are careful to caution that their study may not be generalizable to patients with less advanced disease and suggest that other patient populations deserve evaluation. As a medicine resident and junior practitioner, I learned from wise and experienced mentors that examining each patient, albeit often in an appropriately focused fashion, should be a part of each patient encounter both in the inpatient and outpatient environment. After more than 30 years of examining patients and teaching learners physical examination techniques, I can confidently attest to its value in both medical management and in establishing and maintaining empathetic doctor-patient relationships. It is reassuring to learn from this well-executed study that this longstanding ritual is highly valued by patients.
In summary, this important study by Kadakia and colleagues emphasizes the patient-perceived value of one of the fundamental attributes of being a physician and should propel us to examine patients almost every time they visit. It also provides reassurance that even the sickest of the patients still value the physical examination for both its pragmatic value and for the equally important symbolic demonstration of caring.