It is 2 o'clock in the morning. So far six patients have been admitted during my overnight shift. As the resident on call, I am expected to take a history, perform a physical exam and review lab results and imaging to diagnose and manage these patients' illnesses. One patient, a 45-year-old man, complains of sharp abdominal pain. The CT scan of his abdomen that was done in the emergency room was, as we say in medicine, "unremarkable."

I am debating whether to perform a complete physical. What more will I learn from examining his abdomen that the CT has not already gleaned? While I know that he expects a full exam -- the physician's trademark -- I am already running behind. Nurses are paging me with medication requests for the three other patients I have yet to evaluate. I am swamped, so I do the bare minimum: a cursory physical exam.

Like many of my fellow residents, I am little trained in the "art" of medicine. We embarked on our medical careers during an era of dizzying advances in technology. Unlike our more seasoned attending physicians, we grew up in the shadow of modern medicine, where imaging has supplanted clinical skills. An echocardiogram (not the swishing sound we hear through a stethoscope when the heart's valves close) tells us whether a patient has a heart murmur. An MRI (not our neurologic exam) tells us a patient suffered a stroke. Lab tests (not the patient's swollen, warm fingers) tell us that she has rheumatoid arthritis.

I wonder what my role models -- senior clinicians who seem to know what ails patients just by looking at them -- would think of my lost faith in the physical exam. Throughout my training, I have called upon them to discuss patients. These attending physicians take me into the patients' room and kindly show me how to make a diagnosis by homing in on one or two important tests in a physical exam. I want to emulate their clinical acumen, but I worry that I cannot.

Trainees like myself face more paperwork, menial tasks and the need to master a daunting range of medical innovations. We dictate discharge summaries and transport patients to their tests while trying to stay abreast of evidence-based medicine and the most current tests available. Yesterday, cholesterol levels indicated coronary artery disease, but today it is C-reactive protein. It is no surprise that residents struggle to maintain their physical diagnosis skills when they hit the wards.

Time constraints also discourage performing a complete physical during routine office visits. The managed care system pushes doctors to see patients as briefly as possible. In many busy practices, patients are scheduled every seven to 12 minutes, although a complete physical exam alone takes at least seven minutes to perform properly.

"The problem is that it is easy for a doctor to spend very little time with a patient and just order a CT scan," according to Mark Swartz, author of the well-respected Textbook of Physical Diagnosis and director of the Morchand Center for Clinical Competence in New York, which trains medical students to perform a proper history and physical. "Had the doctor spent more time speaking with the patient, he may have recognized that the patient did not need the test in the first place. It is just easier to do a brief history and some part of the physical, and send the patient quickly off to a test," said Swartz.

Salvatore Mangione, a pulmonologist at Philadelphia's Jefferson Medical College who has written extensively about diagnosis via physical exam in modern times, contends that the waning of physical exam skills epitomizes the state of medical care in the United States. "It symbolizes the loss of medicine's soul. Patients are no longer the primary focus; they are nothing more than an image or lab value. Many times physicians look at the chest X-ray before even speaking to the patient. The loss of this human interaction shows how the patient has become irrelevant in today's health care environment."

"It is like Siamese twins," Mangione continues. "If you separate the humanistic aspect from the science, you risk killing them both."

Is the physical exam dead, or is it only on life support?

A Stethoscope-less Physician

 

There is a growing sense among medical educators that proficiency in physical diagnosis is waning. A 1997 study in the Journal of the American Medical Association (JAMA) evaluated whether 453 residents and 88 medical students could identify abnormal, clinically important heart sounds on tape. Researchers found a disturbingly low identification rate -- residents recognized only 20 percent of the commonly encountered pathologic cardiac sounds they heard. In another study that used taped sounds, cardiac fellows (physicians studying to become cardiologists) recognized structural heart disease only 22 percent of the time. These advanced trainees did no better than medical students. Other studies have demonstrated that physical exam skills are at their peak during medical school, then decline thereafter to embarrassingly low levels of proficiency.

Research shows that less than one-fourth of all internal medicine programs offer structured teaching of physical diagnosis. Formal teaching has moved from the bedside to the conference room. Cases are now discussed at the table or podium instead of the bedside, where a patient's interesting symptoms and physical findings can be presented to trainees. The days of making rounds on hospitalized patients with senior clinicians are increasingly rare. Formal teaching of physical diagnosis is relegated to junior faculty.

At the same time, the tools of the trade have vanished from doctors' pockets. No longer do we carry ophthalmoscopes to examine the retina, an essential way to diagnose diabetic complications or hypertension. Reflex hammers and tuning forks -- equipment essential for the neurologic exam -- no longer weigh us down. Mangione has joked with his students that he thinks medicine may be headed toward the stethoscope-less physician.

The turning point took place in the mid-1970s, when the American Board of Internal Medicine (ABIM) ceased testing residents' proficiency in the physical exam. Tests of physical exam skills were both difficult to standardize and expensive. Since testing drives curriculum and pressures residents to learn specific subjects, residents no longer valued the physical exam.

Licensing bodies are aware of the gap in trainees' education and knowledge and are trying to refocus residents' priorities.

The ABIM requires internal medicine residents to examine patients and record their findings in a logbook, while faculty members rate the residents on their interview, physical examination and counseling skills. Another group, the National Board of Medical Examiners, plans to implement in 2005 a licensing exam to assess medical students' ability to take a history, perform a physical and communicate effectively with patients.

But should the physical exam be resuscitated?

Man vs. Machine

 

The physical exam is the study of a patient using the five senses. We see the distended abdomen of a patient with liver failure. We hear the telltale crackles of heart failure in a patient's lungs. We even identify a patient who is bleeding from his stomach before we enter the room by the unforgettable, fetid smell of digested blood wafting through the hospital hallway.

The ability to diagnose illness has hinged on the time-honored "H&P," as the history and physical is known. "History is the most powerful diagnostic tool available to the internist," according to one of the principal medical texts, Cecil's Textbook of Medicine.

Doctors typically agree with this claim. In most cases, physicians believe a diagnosis can be made based on history alone, with the physical exam providing additional evidence to support or refute their hypotheses. Many studies, even recent ones, have come to the same conclusion. Research reveals that history led to the correct diagnosis 80 percent of the time, while the physical exam helped doctors make a diagnosis approximately 10 percent of the time.

The physical exam offers only indirect evidence of a disease. The undisputable value of technology is that it provides us a noninvasive way to see into spaces of the body that we could never view directly. Prior to imaging, surgeons often had to cut patients open to make a definitive diagnosis.

One disease in particular -- appendicitis -- has been a diagnostic conundrum.The appendix, about 10 centimeters long and one centimeter wide, juts off the colon in the lower right side of the abdomen. When the appendix is blocked, its walls become inflamed and the tissue eventually dies. Uncomplicated appendicitis is easily treated by surgically removing the appendix. But when left untreated, gangrene sets in and the appendix perforates, spilling bacteria into the abdomen. Timely intervention is critical because delayed diagnosis increases complications and mortality. In cases where the diagnosis is made late, the mortality rate reaches 15 percent.

In some patients, early symptoms can be subtle. Patients may notice only vague abdominal pain or indigestion, and an abdominal exam may add little to the clinical picture. Later on, patients may describe more distinctive symptoms -- pain that migrates to the right lower quadrant, nausea and anorexia. The physical exam also provides obvious clues over time -- the patient's belly becomes exquisitely tender and the slightest jostle causes pain.

Historically, surgeons favored operating early on patients with vague symptoms to minimize the risk of perforation, even when they were unsure of the diagnosis. Surgeons walked a tightrope of diagnostic uncertainty, accepting that normal appendixes would be found in 20 percent to 40 percent of patients undergoing surgery for suspected appendicitis.

CT of the abdomen has changed all that. When a surgeon's clinical impression is uncertain, CT offers an accurate, noninvasive way to diagnose appendicitis. In fact, CT had an overall accuracy of 94 percent in one study of emergency room patients with ambiguous symptoms and physical exam findings of appendicitis.

In another study, researchers found that patients who underwent CT were operated on sooner, reducing the perforation rate from 22 percent to 14 percent. Likewise, when CT was used, only 7 percent of patients taken to the operating room did not have appendicitis. Another advantage of CT is that the images helped doctors discover alternative diagnoses in half of patients in whom appendicitis had been suspected.

Now, in emergency rooms across the United States, patients undergo CT scans before a surgeon, the physician most adept at assessing abdominal pain, even has a chance to examine them. Should all 3.4 million patients who seek medical care for abdominal pain each year have a $1,000 test instead of relying on a clinical exam by an expert physician?

In the 1970s, researchers started to rigorously study whether there was evidence to support a lot of what was being done in medicine: Studies were conducted to determine whether patients improved with treatment, while others aimed to evaluate the accuracy of diagnostic tests. Evidence-based medicine was born.

Researchers began to view the clinical exam as just another diagnostic test and started to investigate its accuracy. Previously the value of the history and physical was considered self-evident, and these basic tools of medicine were handed down from generation to generation without being subjected to scientific evaluation. More than 250 physical exam maneuvers, like tapping on the liver to determine its size, have been taught for centuries without being validated by research.

Since 1992 JAMA has published 45 review articles as part of a series called the Rational Clinical Examination to separate the wheat from the chaff. "The mission of the series is to sort out what is useful from what is useless," said David Simel, editor of the series and professor of medicine at the Durham Veterans Affairs Medical Center in North Carolina. "Physicians can then focus on the parts of the history and physical that will allow them to make a diagnosis, not exam maneuvers that are unhelpful."

The series editors believed that, like laboratory and radiologic tests, symptoms and signs have a measurable value that can make the physician more or less confident in her diagnosis.

When evaluating the strength of a test, doctors look at two statistical measurements -- sensitivity and specificity. The ability of a test to correctly identify people with a disease is called its sensitivity, while its ability to correctly identify people without a disease is called specificity. A good test is one that will be positive for almost all those patients with a disease and negative for almost all those without. The higher the sensitivity and specificity, the better the test.

In the 1996 JAMA article "Does This Patient Have Appendicitis?", researchers reviewed the medical literature to establish the accuracy of the history and physical for detecting appendicitis. Investigators discovered that particular symptoms and signs were highly indicative of appendicitis, and the more indicators the patient had, the more certain the physician could be of the diagnosis. For instance, increased abdominal pain during the "psoas test" (where the patient elevates his right leg against the examiner's hands) is believed to indicate a psoas muscle that is irritated by an inflamed appendix. The specificity of the psoas test is 95 percent, meaning that a positive psoas test essentially confirms appendicitis.

Simel believes that the clinical exam is specific enough to diagnose appendicitis in the right setting. "For the classic case -- an adolescent with right lower quadrant pain and a rigid abdomen -- I don't believe additional testing is necessary. I personally believe that just because a test exists, it doesn't mean we have to use it as long as there is evidence to support our clinical judgment and actions. On the other hand, physicians recognize that they may be criticized, rightly or wrongly, if they don't use more available diagnostic modalities. It creates a distinct dilemma."

The Power of Touch

 

For the physician, examining a patient is a diagnostic tool; for the patient, it can be therapeutic in itself. "Patients benefit by being touched when they feel wounded or vulnerable. Once people become ill, the interpersonal distance we maintain in our society collapses," said Mangione. "The physical exam offers the touch and reassurance a patient desires when ill or scared."

The physical exam also builds rapport between the physician and patient. In "The Doctor's Touch: Tactile Communication in the Doctor-Patient Relationship," an article that appeared in the Southern Medical Journal, John Bruhn argues that tactile communication is fundamental to a compassionate doctor-patient relationship. "Tactile experience is a means to intimacy and usually signifies that a special type of relationship exists."

Lia Munden moved to the United States from Milan years ago. Medicine, for Munden, is a family matter -- she came from a family of doctors who practiced medicine by paying house calls with black bag in hand. In her 88 years, she has witnessed the modernization of medicine.

"I am resigned to the idea that the world has changed and that technology is reigning. I don't, however, think the advantages of technology compensate for the loss of the human relationship," said Munden. She fears that the physical exam, an essential part of the doctor-patient relationship, has been sacrificed.

"It bonds you to your doctor," according to Munden. "The physical intimacy that is part of the exam makes you feel close to your doctor. All patients, like myself, want to have a close relationship with their doctor. And, as with all relationships, it is physical contact that makes the relationship close."

With each passing year, Munden has more medical problems. "I try not to worry about my health, but it is difficult to get old," said Munden. "When I have a complete physical exam -- when the doctor listens to my lungs and heart and examines my tummy -- and finds nothing, I feel very relieved. Everything checked out fine. Sometimes when the doctor just listens to me talk about my symptoms, I feel better."

Munden knows firsthand why the physical exam is important. Years ago her physician discovered a small breast mass, later diagnosed as cancer, during her yearly routine physical. Munden has been cured of her cancer but refuses to undergo mammography anymore.

"Mammograms cost more to society than a visit to the doctor. And besides, it hurts. I have enough faith that my doctor will do a good clinical exam that I am not going to put myself through a test that hurts at my age."

Many patients, like Munden, expect a thorough physical exam when they visit their doctor. A study of 400 patients in the Journal of General Internal Medicine found that 70 percent expected a physician to perform a physical exam during routine visits. Of all the specialized testing available, the majority of patients thought only blood work was important. Patients rated their visits as less satisfactory when their physician did not examine them.

Student as Teacher

 

Now I join the next generation of teachers. Four years after my first class in physical diagnosis, I am teaching the craft to second-year medical students. Every week I meet with them to review physical exam techniques as we practice on hospitalized patients who generously donate their time.

My students, after years of studying science from books, eagerly await interactions with patients. They want to learn each exam maneuver and ask me questions about obscure aspects of the physical exam that I have not considered since I took my class in physical diagnosis.

I do not want to (and probably could not) go into the minute details of every technique in the book. I want to teach them the techniques that yield valid information and dispense with those that do not. I want to teach them to use the physical exam to determine which supplemental tests are appropriate. I want to teach them to reassure a patient by listening to her lungs or by touching her shoulder.

I will do my best to teach all of these things. However, the momentum of medical technology is strong, and it nurtures a fiction: that human judgment can be replaced by ever more powerful machines. Technology will always be operated by humans, with its output subject to human interpretation and even error. Recent changes in medical education notwithstanding, the physical exam will continue to fight for its rightful place in the examination room -- as long as the CT scanner is waiting outside.•

Jennifer Obel is a third-year resident at a hospital in Chicago. She has previously written for Health about the use of CPR on the terminally ill and the misuse of outcome data.