Lamenting the Demise of the Physical Examination

          It was in a top tier medical center, that I recently found myself in the unfamiliar role of the patient rather than the doctor.  Somehow the dynamics seemed different than they had during all the years that I had orchestrated this same scenario.  Thankfully, I only need to visit the doctor once in the while and then only for routine matters.  But this time, and I have noticed it increasingly since then, there was a change.  I sat fully clothed on the exam table while the doctor sat with his back to me staring into a computer.  He read from a standard set of questions and each of my brief answers brought on a short burst of typing until the next question.  With the questions over, my doctor turned toward me and really looked at me for the first time.  After a cursory glance, he listened through my shirt with his stethoscope to maybe one breath from each of my lungs and then he placed it somewhere in the vicinity of my heart for what couldn’t have been more than a few beats.  “Everything looks fine”, he exclaimed.

          To say that there has been a revolution in medicine since I was trained would be an understatement.  The advent of sophisticated imaging devices in particular has changed the way medicine is practiced and has been a life-saver for many patients.  But it has come with a price, both literally and figuratively.  Not only have health care costs skyrocketed, but patients have also paid in other ways.  Recently trained doctors rely more on testing and less on physical examination to make a diagnosis than we did in ‘the old days’.  Back then, the ‘laying on of hands’ not only cemented the doctor patient relationship, but it also provided a sense of reassurance to the patient…reassurance that the doctor had really given you a good check up and reassurance that your doctor really cared about you as a person.

          Along with all the other courses first year medical students took when I went to medical school, we spent the entire year dissecting cadavers.  In many medical schools today gross anatomy is either optional or nonexistent.  I must confess that this aptly named course was my least favorite, but by actually seeing all the parts of the body up close and personal we really did learn anatomy. During the second year of medical school we began to apply what we had learned in anatomy and it became quite apparent how it related to the physical exam.  We had a course called ‘Physical Diagnosis”, which we affectionately referred to as P-Dog, using a small maroon textbook titled “Bedside Diagnostic Examination”, by DeGowen & DeGowen.  This now classic manual was compact enough that we could carry it with us on our rounds.  That year we also got black bags loaded with the tricks of the trade and donned our short white coats in preparation for our first physical exam.  To this day, I still remember going into the hospital room with one of my classmates to meet our very first patient and awkwardly asking all the questions in the history and review of systems that we had practiced.  And I will never forget this kind older gentleman who let us poke and prod him, all the while probably thinking he had been visited by Doogie Howser.

          The physical examination was constantly stressed by our professors in medical school and we learned much from watching them perform the exam.  To me neurologists have always been the masters of the physical exam.  Back then they could easily be distinguished from other physicians by the extra large percussion hammers with a wheel on the end that they all seemed to have…so large, in fact,  that it often extended out through the top of their black bags.  Alas, one hardly ever sees a doctor carrying a black bag any more.

          Later in my training, I remember examining a woman who was being admitted to the hospital.  It wasn’t unusual for each medical student or intern to get 20 admissions in one night back then, and even working around the clock, it was difficult to get everything done.  The following morning I presented her case to the senior resident while he scrutinized my write up.  When I was finished, he asked if I had examined her cervical lymph nodes…a question for which he already knew the answer.  As a novice, I had skipped something that I thought was unrelated to her reason for admission.  When I confessed that I had not examined her cervical lymph nodes, he asked in a mild but, for me, withering tone, “You didn’t think it was important?”  I had no answer.  That was a good lesson and I have never forgotten it or the resident who set me straight that morning.  Since then, no matter how busy I have been, I have always tried to remember the importance of a thorough physical examination.

          I know.  Things are different now.  Every year the body of information that physicians must learn grows exponentially.  Of necessity, medicine must be practiced differently, but I am encouraged to see that there is a small, but growing renewed emphasis on the importance of the physical examination at some medical schools.  And I must say, that I am constantly impressed with the young physicians I encounter who are being trained in our medical schools these days.  Finally, I am happy to report that I am adjusting to the new dynamic and my doctor and I are getting on just fine.  We truly do have the greatest health care system in the world!