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What is a physical examination worth? As I stare at a list of my upcoming patient appointments in my primary care clinic and try to decide who shall come into the office despite the coronavirus disease 2019 pandemic, this question paralyzes me.
In the 15 years that I have been a physician, the physical examination has always occupied a precarious space for me. As a resident, the reams of information I had on patients before I stepped into their room made it tempting to do the “quick physical exam” that Robert Hirschtick bemoaned in a recently republished essay.1 More recently, my accountable care organization’s emphasis on increasing our volume of Medicare annual wellness visits, which do not require a physical examination, and recommendations from some groups against routine physical examinations in asymptomatic patients2 has me second guessing why I examine healthy elderly patients.
As our primary care practice has pivoted to telehealth and the physical examination has been ripped away from me, I find myself reflecting on what value the examination has. It is clearly needed at times to make a diagnosis. But I now realize the other ways I use the examination to advance care and its significance to my own well-being. It is a means through which I pause and physically connect with patients, I demonstrate my knowledge and authority, and is a tool I use to persuade patients and reevaluate their narratives.
Many physicians would say that some diagnoses cannot be made without examining a patient in person. I am not sure how I am supposed to distinguish central vs peripheral vertigo, diagnose otitis media, or determine if someone has orthostatic hypotension without examining a person in front of me. In addition, many of us have cases where an unanticipated finding on examination feels as though it saved a patient’s life. A discovery of an irregular mole, a soft tissue mass, or a new murmur—I do not forget these cases, and I do not think the patients do either.
What was less apparent to me before the pandemic was how a thorough physical examination provides a measure of objectivity that can help me rethink a patient’s narrative. I work in Maine, which has its share of stoics. A patient recently came in feeling a bit tired but felt it was nothing, likely as a result of working too hard. His examination suggested he was in heart failure. If I had not been able to listen to his heart and lungs, and examine his jugular vein and lower extremities, I may have put too much weight on the patient’s lack of concern and missed the diagnosis.
When patients and I disagree on a plan, the physical examination not only provides data, it also acts as an arbiter. For instance, patients sometimes feel a need to use antibiotics to treat a respiratory infection. If I communicate that results of their lung examination are clear and that their oxygen saturation levels are normal, they often feel more reassured that they do not need medication.
The examination, though, is more than a tool that informs diagnosis and treatment. I now realize its value to me. The quiet moments when I am listening to a patient’s heartbeat and breath can be centering, similar to the part of a meditation where one refocuses on one’s own breathing. Abraham Verghese has commented extensively on the role of the physical examination as ritual and its importance to patients; he also has observed how this ritual brings physicians satisfaction through human connection.3 Only now have I come to recognize the examination as a ritual that is restorative and brings me calmness and confidence.
In an admission of my own insecurity, the physical examination remains one of the few domains where I maintain a sense of professional skill and authority. I have never been much of a proceduralist. The mainstay of what I offer to patients is the ability to listen to them, to use critical thinking skills, and to offer my knowledge and experience. But those skills are sometimes challenged in a world where patients research their own health and develop their own medical narratives. The physical examination remains a place where I offer something of distinct value that is appreciated.
Finally, the physical examination is one of my routines, 15 years in the making, that has been taken away with the emergence of the pandemic. Starting with the principles of active listening, gathering data, and creating a broad differential, I had developed a way of practicing medicine that I felt worked more often than not. While I continued to reevaluate this process, I did not question each day whether a patient needed a physical examination. But the pandemic has forced me to deconstruct my routine, including the physical examination, in a way that leaves me on uncertain ground. This has been emotionally exhausting and unsettling.
Not all is lost with the emergence of telehealth. At least in these early phases, virtual visits seem to allow me to connect more frequently and easily with patients. With telehealth, I can see patients in their home environments, which often provides me with new information on factors that influence their health behaviors. Virtual visits respect a patient’s time. And, of course, in this pandemic when social distancing is so important, telehealth keeps patients safe. As the months go by, I will adapt and undoubtedly learn new ways to gather physical examination data. Wearable technology or guiding patients through self-examinations will offer some creative approaches to obtain tele-examination findings.
In the past 10 years, with the emergence of the electronic health records and team-based care, we primary care physicians have found ourselves on unsure footing with our identity and way of practicing frequently shifting and disrupted. I have no doubt that when the dust settles from the coronavirus disease 2019 pandemic, things will once again be changed, including a reexamination of the role of the in-office physical examination.
This examination, in its current form, may be left behind. As Michael Rothberg writes in a recent JAMA piece, some physical examinations, in our current health care environment, can have unintended costly and risky consequences, leading to “invasive and potentially life-threatening tests.”4(p1683) While I am sympathetic to this rationale and recognize the benefits of telehealth, I struggle to find equipoise. In attempting to keep patients at a distance, I am losing touch with a part of my professional identity.
Corresponding Author: Paul Hyman, MD, Mid Coast–Parkview Health, 329 Maine Street, Suite A200, Brunswick, ME 04011 (email@example.com).
Published Online: August 24, 2020. doi:10.1001/jamainternmed.2020.3546
Conflict of Interest Disclosures: None reported.
Additional Contributions: I thank Jonathan Shaw, MD, of Stanford University School of Medicine for his editorial feedback. He was not compensated for his contributions.
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Hyman P. The Disappearance of the Primary Care Physical Examination—Losing Touch. JAMA Intern Med. Published online August 24, 2020. doi:10.1001/jamainternmed.2020.3546
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