I keenly remember the thrill of making my way to the medical bookstore as an early first-year student to buy my first stethoscope.
Although receiving the short white coat at the start of medical school symbolizing the transition into the medical profession was incredibly meaningful, the stethoscope was a much more tangible indicator of the training in perhaps the most special of medical skills that lay ahead – the physical examination.
Although performing physical examinations is not limited to physicians, it is such a key component of the diagnostic process and the physician-patient relationship that it is virtually impossible to overstate its importance.
Why is this? In the thousands of years before the advent of our current technology, gathering a detailed medical history and examining patients was pretty much the only diagnostic method available. But perhaps as important, if not more so, is that touching patients as part of the physical examination has always played an integral role in establishing a unique relationship with them. It is a form of intimate communication that is profoundly human and defines the doctor-patient relationship as something far beyond a simple business transaction. It can help establish trust and bond between patient and caregiver. It can also convey caring and empathy in a way that words cannot. And while physicians typically view the physical examination as a diagnostic tool, patients frequently receive therapeutic value from the tactile aspects of the physical examination, what some term “a healing touch.”
Yet, over recent decades there has been diminished patient-physician interaction in general, and a concurrent decrease in the actual physical contact between doctors and their patients. I’ve been impressed by the increasing number of my colleagues who readily acknowledge that they intentionally do not examine their patients routinely and do so only if compelled by fairly narrow clinical circumstances.
The reasons for this are many and familiar. Remarkable advances in technology, particularly imaging, have decreased the perceived accuracy and value of the physical examination in the diagnostic process (why examine the heart when I can just get an echo?). Plus, administrative and regulatory burdens, documentation requirements, and increased patient throughput have significantly decreased the time that physicians have to spend with their patients with a resulting perceived loss of opportunity for the physical examination. But there is a great cost to this decreased patient contact, both in terms of the diagnostic process and its effect on both patients and physicians.
From a diagnostic perspective, we are likely not taking advantage of the physical examination as a tool that can provide invaluable clinical information. Examining patients is extremely low cost (except for the time it takes to perform the exam correctly) and of low risk to the patient. Plus, many physical findings (or their absence) have well-documented, validated diagnostic value similarly to other more technical studies – information we can use in helping us think through what is going on with our patients. Most of us recognize the power of the physical examination not as a method of supplanting more advanced technology, but as a means of augmenting our clinical thinking and guiding the use of technology in a more reasoned and intentional way.
We also know that the diminished focus on the physical examination may result in significant diagnostic errors. There is evidence suggesting that diagnostic accuracy may be significantly negatively affected by either simply not performing an examination or missing important findings when an examination is done, something that may occur with increased frequency as physicians become less adept at using the physical examination routinely as part of the medical care process.
But even more importantly, what we may lose with decreased physical contact are the less tangible but critically important effects on both patients and doctors. Patients are incredibly sensitive to the humanizing aspects of touch in the context of a therapeutic relationship. This seems to be particularly true in people who are sicker or have more complex medical issues who perceive being touched as an indication of interest, concern, and sense of commitment on the part of the physician to partnering with them on addressing their medical issues. However, even in healthier patients where there is less objective data regarding the benefits of the physical examination in improving clinical outcomes, the benefits of touch between physician and patient as part of the therapeutic relationship are extremely valuable even if they cannot be readily measured. Because of this, I try to incorporate some element of physical examination into every patient encounter, recognizing that in some cases the act of the examination is more important than any expected findings. Even in my healthiest patients, a focused examination of the heart and lungs goes a long way toward building the unique bond that optimally exists between patients and their physicians.
However, another aspect of the physical examination that is frequently overlooked is the positive effect it can have on us as physicians. I hear frequently from colleagues about how happy they would be if they would just be left alone with their patients without the increasing pressures of time and the intrusion of administrative and documentation burdens that have now reached into the exam room. These are the things that interfere directly with the doctor-patient relationship and likely contribute to the high degree of stress and burnout we may feel. Although skipping the physical examination and avoiding the touching of patients may improve efficiency, it may also rob us of an aspect of care that is so unique to medicine and special in our profession. Perhaps instead of seeking efficiency, a return to interacting more closely with our patients, including examining and sharing touch with them, would help us rediscover one of the great rewards of being a doctor.
To touch and be touched is part of the process of getting and staying well, both for patients and physicians.
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