Commentary Corner: Morbidity and Mortality of the "Physical Examination"
After two months of vacation, I was looking forward to something educational. Even though my vacation was not yet over, I found myself in the auditorium of the old college building on the third Thursday of the month for the routine departmental Morbidity and Mortality conference. I sat at the very back row and waited expectantly, prepared to be immersed once again in the world of medical jargon. I recognized the professors; the one who taught us renal physiology in our second year pathology course, there was also the one who led small group sessions where we explored and discussed how to be great doctors, and there was the one who grilled me mercilessly as I stammered through patient presentations during liver rounds in my third year medicine rotation.
The chief resident introduced the second year medicine resident and he started his presentation as I smiled contentedly. He was delightfully eloquent and I was admiring his confidence and articulate presentation when I was forcibly struck by an overwhelming sense of disappointment. I waited expectedly for someone to raise their hand, to point out what was so obviously wrong, to stop him from continuing, to make him rectify his presentation, but the auditorium was quiet, full of people expecting to learn from patient care mistakes and, perhaps, waiting to silently assign blame.
Let me explain. The resident began his presentation by introducing the patient's medical complaints. He provided detailed information of the patient's admission laboratory values and the patient's hospital course. Throughout the presentation and the ensuing discussion, a vital piece of information remained mistakenly unacknowledged. Nowhere in the one-hour discussion of this patient and the medical care he received did anyone discuss who the patient actually was or what he looked like; in other words, I mean, in medical jargon, the physical examination. In the course of third year rotations, as we courageously practiced the art of examining our patients, I learned to skip, to pass on seemingly mundane practices like looking into the patient's ears, especially if he presented with chest pain! I learned to auscultate the chest and listen to the lungs but passed on palpation and whispered pectoriloquy? What was that again? Oh, I went through the cranial nerves, I was a budding neuroscience expert after all, but skipped the gait tests, the patient was obese was my excuse for not checking them. I remember now the dedicated course directors who tried to instill the importance of fully examining our patients. I had hoped that as I progressed in my career, that during residency as I learned to perform the physical examination and actually practice them the right way and every day, that I would have these mentors by my side, to correct my mistakes and to chide me if I ever skipped.
And here at the basement auditorium of the college building, surrounded by oil paintings of pioneers in the field of medicine, it was with a sense of doom that I acknowledged the dying art of the physical examination. I have read numerous articles about the importance of examining the patients, read many opinions from practicing physicians about the demise of the physical examination, still I did not comprehend how quickly the rate of decline was, nor did I expect that it would be quietly accepted. There have been steps taken to emphasize the practice of examining a patient. Nationally, graduating medical students have to take the clinical skills examinations, and individual medical schools, such as Stanford medical school, have initiated specific medical courses to teach medical students how to properly examine a patient. All these efforts are admirable and important, and time will tell if they will result in a change.
Today, as I anticipate the end of my vacation and the beginning of another clinical rotation, I look forward to examining my patients, to using my stethoscope again, to spending endless hours rounding on patients, and I humbly realize that I will not be able to practice any field of medicine without knowing who the patient is, without examining the patient. The chest x-ray might show the lung infiltrates but my fingers could just as easily drum out the consolidation, the MRI scan might show the spinal epidural hematoma but the neurologic exam would more easily elicit the loss of motor and sensory function, the ultrasound might show the fluid collection of ascites but the fluid wave is pretty interesting to elicit and observe, the bone marrow biopsy might diagnose the leukemia but the observed rash is just so classic, the blood test might reveal decreased vitamin levels but the shiny tongue is a dead giveaway, the transesophageal echocardiography might show aortic dissection but using those blood pressure cuffs are not so intimidating. Yes, I will percuss, I will auscultate, I will observe, I will listen… I will examine my patients. Will you?
Olatilewa O. Awe, MSIV
Jefferson Medical College