Dean On Campus Blog

Let’s Never Lose the Art of Examining the Patient

Elizabeth Eisenhauer, Professor of Oncology at Queen’s, shared with me an op-ed piece from the New York Times by Abraham Verghese, a Professor for the Theory and Practice of Medicine at the Stanford University School of Medicine. Published last February and entitled, “Treat the Patient, Not the CT Scan,”1 the article focused on the need for medical educators to constantly remind us, and our learners, of the importance of the physical exam. Verghese opined that Watson, the computer of Jeopardy fame, might well be just as good, or even better than a physician at arriving at a diagnosis. Watson, Verghese reminds us, would have access to the entire data set of all patients in the hospital. It would also be constantly digesting current information from the web, and would be able to, in an algorithmic fashion, prioritize diagnoses and treatment for any patient.

But Verrghese goes on to say that “this computer record creates what I call an “iPatient” — and this iPatient threatens to become the real focus of our attention, while the real patient in the bed often feels neglected, a mere placeholder for the virtual record.” He suggests, that Watson may have not been able to answer this Jeopardy question “An emergency treatment that is administered by ear… What are words of comfort?”1

Jill Max, from Yale Medicine, agrees with Verghese. She suggests, “Physicians once relied on seeing, hearing and touching a patient to make a diagnosis. Technology has enhanced and sometimes replaced those skills, but many doctors lament their decline.”4 She tells the story of a young patient who presented with pulmonary embolism. He was admitted to hospital and had every test known to mankind, all of which were negative. Then, an experienced physician, noticing that the patient was muscular, did what is known as an Adson’s test. She reports… “Duffy, professor of medicine (hematology), had an idea what the problem might be. To confirm his suspicions, he performed a simple test known as Adson’s maneuver: With the patient’s arm straightened, Duffy placed a finger over the pulse at the wrist and then moved the arm behind the young man’s back. When he asked the patient to turn his head, the pulse disappeared; when he looked forward, the pulse returned. Duffy deduced that the man was suffering from thoracic outlet syndrome, a compression of the blood vessels beneath the collarbone that cuts off blood flow to the arm. Surgery repaired the problem.”

To be sure, we at Queen’s, as at every other medical school, go to great pains to teach our students the art and science of history taking and physical examination. In fact, we have a whole center dedicated to that element of our curriculum. But often, as soon as our students get to the wards of a hospital, they end up spending countless hours of their day in front of a computer. There is a risk that all of our teaching about the importance of the history and physical can be undone by the focus on “the data” and our obsession with technology.

Jennifer Gibson, in her Brain Blogger Feed column, suggests “the health care system and its practitioners are under increasing pressure to provide efficient, effective, and consistent care to patients. Patients want to be treated as an individual, not a case number.”5

We have long since been convinced that “patient-centered care” is fundamental to modern medical practice. Undoubtedly holding dearly to the long held art of the physical examination is central to patient-centered care.

If you have any stories about your experiences with importance of “the physical examination,” please share them with our readers, or better yet, please stop by the Macklem House…my door is always open.

Richard

  1. http://www.nytimes.com/2011/02/27/opinion/27verghese.html?_r=2&scp=1&sq=treat%20the%20patient,%20not%20the%20ct%20scan&st=cse
  2. http://www.google.ca/imgres?q=art+of+physical+examination&um=1&hl=en&biw=2560&bih=1181&tbm=isch&tbnid=tpoSYjdof5PtAM:&imgrefurl=http://www.comprofessor.com/2010_09_21_archive.html&docid=a-r72eSP6R6coM&imgurl=http://2.bp.blogspot.com/_bE7Mw-gkKG4/TJlGeg-482
  3. http://www.google.ca/imgres?q=watson+jeopardy&um=1&hl=en&biw=2560&bih=1181&tbm=isch&tbnid=II82Lh1N6QDj7M:&imgrefurl=http://gizmodo.com/5762296/watson-crashed-multiple-times-on-jeopardy-plus-other-watson-tidbits&docid=3UAF95cyecs3TM&imgurl=http://cache.gizmo
  4. http://www.med.yale.edu/external/pubs/ym_wi09/feature3_physical.html
  5. http://brainblogger.com/2010/10/31/the-art-of-medicine/

20 Responses to Let’s Never Lose the Art of Examining the Patient

  1. Susan Phillips says:

    Verghese’s novel, “Cutting for Stone” is one of the best ever. In a way it says what Sackett said originally about EBM – that it’s about taking the research but applying it to, and filtering it through who the patient is in a patient-centred manner. We all say these sorts of things but Verghese’s writings illustrate how to actually do this. Thanks for sharing the info about his op ed.

    • reznickr says:

      Dear Susan,

      Thanks for sharing your views. I haven’t yet read “Cutting for Stone”, but Elizabeth had mentioned it was a great book.

      Richard

  2. Ralph Yeung says:

    It certainly is easy to forget, since we’re all victims of immediate gratification to varying extents, the importance of the patient. Catching an interesting pathology on a CT is so rewarding because it’s right in front of you. Communicating to a patient and doing good is probably just as rewarding, if not more so, just not as immediate. I’ve to admit, we x-ray techs have this problem too.

    Given the topic, Dr. Reznick, you may be very interested in this TED video:
    http://blog.ted.com/2011/09/26/a-doctors-touch-abraham-verghese-on-ted-com/

    • reznickr says:

      Dear Ralph,

      Thanks for sharing your views from the reflection of a health care provider. I must say, I had not thought about the issues from the viewpoint you propose, but it certainly is an interesting perspective.

      Richard

  3. Ian Silver says:

    Sadly, the art of examining patients seems to be in full decline. We routinely get requisitions for imaging studies from the E.D., from the wards or on outpatients stating something like “such and such a specialist will not see the patient until an MRI has been performed.” At least that widespread phenomenon can be attributed to how busy some specialists are. Perhaps less easily explainable are cases such as CT scans of the abdomen and pelvis to rule out appendicitis, only to find on the scan that the patient has had a prior appendectomy, or a CT pulmonary angiogram to rule out pulmonary embolism in a patient with pleuritic chest pain, only to find an acute rib fracture on the scan. Even though many physicians know at least the basics of performing a physical exam, it seems that fewer and fewer still bother these days.

    • reznickr says:

      Ian,

      Thanks for bringing your views to the discussion, and adding further evidence that we, as health professional educators, need to keep our eye on this ball.

      Richard

  4. Henry Dinsdale says:

    The importance of your topic was emphasized by what, at the time, I found to be a surprising comment by a patient at the end of her visit -”I’m so glad you spent more time looking at me than at the computer on your desk. It was a nice change”

    • reznickr says:

      Dear Henry, Thanks for sharing your story. For those of you who may not know, this endorsement of our thought to emphasize the importance of the physical examination, is coming from one of Canada’s most respected physicians.

      Richard

  5. James Armstrong says:

    I will never forget Dr. Dinsdale at morning rounds telling a (somewhat lazy) resident that his diagnosis of ‘cerebritis’ was the diagnosis of physician ‘who is neurologically bereft’. In 1989, I was a medical student on the Gastrenterology rotation. I was paged on a Sunday afternoon by Dr Bill Depew to come to the hospital so that I could observe him examine a patient complaining of arm pain. The question was, did the patient have an axillary DVT? As I recall, she had risk factors (breast cancer, perhaps recent surgery). There was no ultrasound technician in the hospital on the weekend. Dr Depew wanted to determine if a tech should be called in, and he didn’t want to waste money with an unnecessary test. Off we went to the bedside. He took a history, and then said, something like, “Now I don’t know of any physical sign that would prove there is a DVT, but logic would suggest that the veins of the affected arm would drain more slowly, if she has a DVT.” With that, he had her dangle both arms over the side of the bed so the veins would become engorged. The he raised her arms together above her head, and lo and behold, the veins of the affected arm collapsed more slowly. The tech was called in, and the diagnosis was proven.
    This teaching moment has always stuck with me. First, Dr. Depew is perhaps the finest diagnostician who I ever had the opportunity to learn from (and it was a crowded field at Queen’s). He demanded a high standard of keen observation from all of us. He could invent a physical examination technique at the bedside. And he cared about saving taxpayer’s money.
    In 1927 Francis W. Peabody wrote in JAMA that “The secret of the care of the patient is in caring for the patient.” A careful physical examination is an essential part of that care. Computers will never be a substitute for this.

    • reznickr says:

      Dear James, Thanks for your marvelous reflections. I will let Dr. Depew know of your memories. I love the Peabody quote, durable for 75 years!

      Richard

  6. Phyllis Durnford says:

    Part of my career in nursing concerned teaching ‘the art and science of nursing’. My favourite line to my students on the clinical unit was that the first thing they were to do when they stepped into the patient’s space (cubicle, private room, behind a curtain) was to look straight at their patient, introduce themselves-if they hadn’t already-and say hello. While doing that they had to do a visual ‘head to toe’ inspection only. Then they had to ask the patient about his/her condition, and only after that, could they look at whatever device was connected to the patient. My point to them was that the beeping IV monitor wasn’t something life-threatening! Later, as they became more experienced, they learned how to deal with a beeping monitor that did indicate something wrong, and still maintain contact with their patient. People need, and like, to be treated as people, first and foremost. How many times have I had it happen, and had it reported by students and colleagues, that the patient thought someone was a ‘good nurse’ because she/he made the patient, not the technology, the prime focus of attention. It’s even possible to do in pre-hospital situations and in-hospital emergent situations. It doesn’t take long, as one becomes more experienced, and the effect on the patient is clearly discernable.

    To nurses, physicians, and health care technicians, without a patient, the technology is meaningless. Your patient comes first! The technology can help but it’s no substitute for an educated brain and two very observant eyes!

    • reznickr says:

      Phyllis,

      Thanks for your reflections and the wisdom of an experienced practitioner. Indeed, I remember well telling my (surgical) students that their most important job was to, in the first minute of a patient encounter, answer the question… is the patient sick or not sick. And the message was to forget all the numbers, forget the diagnosis, and just look at the patient.

      Richard

  7. Fred Moffat says:

    Richard

    Congratulations on writing about this conundrum – very few leaders in our profession have commented on or even cottoned onto the problems created by electronic documentation in patient care. While EMR systems meet all manner of governmental mandates and may reduce medical errors, they are a major challenge in terms of the doctor-patient relationship and excellence in medical/surgical practice. The history and physical are where the rubber hits the road in our line of work, and EMR systems can be a very real liability in these vital medical arts.

    When used in real time during patient encounters, EMRs are a huge distraction at the very least, and often very destructive of the establishment of good rapport with our patients. They are an affront of sorts to the timeless adage “When all else fails, take the history”. Pay full attention to the patient! He or she does not take kindly to caregivers staring at a computer screen in lieu of engaging them with eye and direct personal contact, nor should they. Patient satisfaction suffers commensurately. For this reason alone I never use a computer in patient encounters of any kind, deferring my electronic documentation to a later time in the day.

    Moreover, the distraction of an EMR during patient encounters often results in loss of very telling nonverbal information gleaned by simple, direct, unimpeded observation. These data are subtle and evanescent by definition, and therefore all too easily missed/overlooked by distracted clinicians. Nonetheless, more than occasionally, information of this type proves critical to appropriate diagnosis and treatment recommendations. My real time documentation is of the pen and paper variety. Easy, low-tech, and neither distracting to me nor off-putting for patients.

    Finally, all too many EMRs are synoptic to the point of gibberish, all in aid of patient safety and the aforementioned administrative mandates. In patient care, perhaps the most important contribution of the medical record is the storyline recorded cumulatively over many outpatient and inpatient encounters. Absolutely priceless in its value to clinicians and their patients alike. While EMRs may have their strengths, this is a huge weakness; of the four systems I work with on the University of Miami/Jackson Memorial Medical Center, two are beyond help in this regard. The VA system is actually the best of the four.

    Again, am absolutely delighted you’ve raised this issue. It needs greater attention than it has garnered heretofore!

    Regards and best wishes, and love to Cheryl!

    FLM

    • reznickr says:

      Fred, why are you always so eloquent! I guess I will have to start asking you to write these blogs! You bring up so many terrific points. And the fact they are coming form a superb clinician sends a great message to our students.

      All my love to Jenny,

      Richard

  8. Rob Cartotto says:

    Richard,

    Well said! I think this is an increasing problem. In the burn ICU where I work as an attending, I regularly have to remind residents that they are expected to go into the patient’s room and examine the patient, even when that patient is sedated and on a ventilator. Recently, a trainee actually told me that “he didn’t realize he was expected to examine patients in the ICU”! There is of course a heavy reliance on tests and lab work in an ICU setting, but there’s simply no substitute for laying hands on the patient. Correcting this disturbing trend starts with the attending physicians setting the example. We all have a lot of work to do.
    Kind Regards,

    • reznickr says:

      Dear Rob,

      Thanks for your message and it’s great to hear from old friends from Toronto. Your message rings all the more true coming form someone who looks after the sickest patients we have to take care of.

      Richard

  9. Marny Ryder says:

    Thank you for this message from a nurse who has worked in the nursing profession for many years in the Yukon. I spent much of my time in small remote communities where there was minimal diagnostic equipment available. The telephone was my link to the doctor who was many miles away, and when I was dealing with a patient, I had to rely on the physical examination, information I could elicit from the patient, and on more than one occasion the old “gut feeling”. Talking to the patients was vital, especially when they were frightened or in such pain that conversation was not an option but facial expressions could provide some valuable clues.
    On my most recent experience, visiting my husband in a large hospital in Vancouver, I was surprised, and dismayed by the team of doctors who would come in to check on him, discuss his test results with their colleagues, and leave with just a brief goodbye.
    It is reassuring to think that Queen’s University is concerned about restoring the “care” to health care and acknowledging the value in the personal touch.

    Thank you.

    Marny Ryder NSc. 1965

    • reznickr says:

      Dear Marny,

      Thanks for your comments, and how meaningful they are coming from someone who has cared for many, especially in a rural setting. You are absolutely right that we have to be preparing our future health professionals to work in a multitude of environments. As you suggest, not all of them will have a 64 slice CT scanner.

      Richard

  10. Garry Willard Meds' 63 says:

    Dear Richard,

    Of all of Sir William Osler’s adages, the most enduring advises us to ” listen to the patient and he will give you the diagnosis”.

    Coupled with astute physical examination, the diagnosis is confirmed by appropriate ancillary testing, be this, for example, a urine glucose, a serum lead level, an EKG with rythm strip, a tomogram of the C-spine, or an MRI of the brain.

    Read in to “listen” and one sees the clinician giving undivided attention to the patient, showing empathy and care, while factoring in to the cerebral computer the data necessary to development of a working diagnosis and treatment program.

    Yes, let us never lose the art of patient examination but equally let us never lose the art of history taking. Clearly both are best learned at the bedside in company of a kind, articulate, incisive and thoughtful mentor (of which there were many in my days at Queen’s and in the Gallie Program in Toronto). Once acquired, these are keypieces in the physician’s armamentarium and, despite no extended warranty, actually last a lifetime.

    Thanks again for your insightful and imaginative blogs. All the best, Garry

    • reznickr says:

      Dear Garry,

      Thanks so much for your lovely remarks and wise advice. I think I agree with you that taking a history is as much or more of an art than the physical examination. Coupled together, they make a wonderful tool; in my opinion, especially meaningful when the initial presenting symptom is either vague or undifferentiated.

      Richard

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