In the 21st century, debate continues concerning the value of the physical examination.1, 2, 3, 4 That such a hallowed and respected ritual of clinical medicine should even be questioned is the result of the remarkable advances during the last 50 years in imaging technology and laboratory medicine. When I was a student and resident in the late 1960s through the mid-1970s, the history and the physical examination were the princes of clinical medicine. The history remains a cornerstone in the evaluation of the patient, but some have questioned whether a detailed and time-consuming physical examination is cost-effective or even accurate in the diagnosis of a variety of conditions. For example, determining whether a patient has abdominal ascites during the physical examination is known to be inaccurate. Other time-honored aspects of the physical examination have also been shown to be of questionable accuracy.
Despite the fact that many aspects of the physical examination have been shown to be of limited value, I remain committed to its performance and do it on a daily basis on both outpatients and inpatients. Why do I persist in doing this ancient, traditional exercise? In my opinion there are a number of reasons for continuing to perform physical examinations on outpatients.
First of all, I continue to find that performing this exercise still can produce important clinical information not previously observed by the resident physicians. One example should suffice: I recently examined a 77-year-old man admitted to my team’s internal medicine service for a community-acquired pneumonia. The resident informed me that the patient’s cardiac examination revealed no murmurs, rubs, or gallops. When I placed my stethoscope on this patient’s chest, I was surprised to note a grade 3/6 murmur, which I recognized as severe aortic stenosis. My residents were amazed when I “guesstimated” the aortic valve area by quantifying the percentage of systole filled by the ejection murmur. Subsequently, when an echocardiogram was performed, my guesstimate was very close to the valve area estimated by the Doppler echocardiogram. Was this physical finding important for this patient? Absolutely, yes! A subsequent catheterization demonstrated markedly elevated left ventricular and pulmonary capillary wedge pressures resulting from severe aortic stenosis. When this patient finished a course of antibiotic therapy for his pneumonia, he underwent an uneventful transcutaneous aortic valve replacement. Currently, many months later, he continues to do well.
Another reason to do the physical examination is that patients expect it and feel better because the physician has spent time examining them. Another recent example demonstrates the value that patients place in the physical examination. The patient had reduced left ventricular dysfunction and clinical heart failure. He had been gradually improving with β-blockade. We had decided to perform an echocardiogram to see if the left ventricular ejection fraction had improved. I examined this patient and then scheduled him for the echo study, followed by a return visit in a week to discuss the results of the echo study and further plans to treat his heart failure. The echo study did indeed show improvement in his left ventricular ejection fraction. I did not feel that it was necessary to examine him for a second time in a week when nothing had changed clinically. The patient saw that I was about to conclude the visit without doing a physical examination, and he said to me “Aren’t you going to examine me, doc?” I explained that I had just done the examination a week before; he countered with the following remark: “Please check me out again; it makes me feel much better when you examine me.” Of course, I examined the patient, who thanked me for taking the time to do this.
I am not the first to suggest that the performance of a physical examination by an experienced physician benefits the patient in ways other than merely the finding of an abnormality. My friend and colleague Abraham Verghese at Stanford Medical School has often written and expounded on the value of the physical examination.5, 6, 7 He and a group of his colleagues have even founded an organization that meets annually to stress physical examination skills and their value.7
In this issue of The American Journal of Medicine, Shrestha et al8 retrospectively studied the value of the digital rectal examination in more than 1200 patients who came to a university hospital emergency department complaining of acute gastrointestinal bleeding. Patients who received a digital rectal examination in the emergency department were much less likely to be admitted, much less likely to undergo endoscopy, and much less likely to receive medical therapy for a gastrointestinal bleed despite the fact that those receiving the digital rectal examination were older, had more comorbidity, and were more often receiving anticoagulation therapy. Thus, this simple and time-honored component of the physical examination was proven to be a useful tool that contributed to clinical decision making.
So what is the answer to the question posed in the title to this editorial? The answer is absolutely yes: clinicians should continue to learn and perform careful physical examinations. This long-standing clinical technique continues to contribute in a cost-effective manner to clinical decision making and hence to the care of the patient.
As always, I welcome comments concerning this editorial on our blog at amjmed.org.
To read this article in its entirety please visit our website.
-Joseph S. Alpert, MD (Editor in Chief, The American Journal of Medicine)
This article originally appeared in the July 2017 issue of The American Journal of Medicine.
-To read “Digital Rectal Examination Reduces Hospital Admissions,” another article relating to this topic follow, this link.
