[Skip to Content]
[Skip to Content Landing]
Views 37,716
Citations 0
Perspective
August 24, 2020

The Disappearance of the Primary Care Physical Examination—Losing Touch

Author Affiliations
  • 1Mid Coast–Parkview Health, Brunswick, Maine
JAMA Intern Med. Published online August 24, 2020. doi:10.1001/jamainternmed.2020.3546

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.

Back to top
Article Information

Corresponding Author: Paul Hyman, MD, Mid Coast–Parkview Health, 329 Maine Street, Suite A200, Brunswick, ME 04011 (phyman@midcoasthealth.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.

References
1.
Hirschtick  RE.  The quick physical exam.   JAMA. 2016;316(13):1363-1364. doi:10.1001/jama.2016.8182PubMedGoogle ScholarCrossref
2.
Society of General Internal Medicine. Five things physicians and patients should question. Choosing Wisely. September 12, 2013. Updated February 15, 2017. Accessed May 8, 2020. https://www.choosingwisely.org/societies/society-of-general-internal-medicine
3.
Parks  T. Dr. Abraham Verghese looks at the patient-physician relationship. American Medical Association. January 20, 2016. Accessed May 8, 2020. https://www.ama-assn.org/delivering-care/patient-support-advocacy/dr-abraham-verghese-looks-patient-physician-relationship
4.
Rothberg  MB.  The $50 000 physical.   JAMA. 2020;323(17):1682-1683. doi:10.1001/jama.2020.2866PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    19 Comments for this article
    EXPAND ALL
    Observation
    Mileham Hayes, MB, BS. | Private Practice
    While I agree with Dr Hyman, some 50 years ago when I was specialising in Edinburgh I walked the wards where Conan Doyle was inspired by Dr Josiah Bell's methods to write Sherlock Holmes. This was "observation" and the then Doyen of Scottish medicine used to pause me at the ward entrance and get me to diagnose the patients before entering. I think I averaged around 19 out of 30 but sometimes more. Later a respiratory physician had me palpate and percuss a chest to diagnose a Pancoast's tumor (there was no Argyll Robinson pupil) and when I did he congratulated me and asked me if I didn't feel 'well satisfied with my achievement' and was most surprised and somewhat put out when I demurred saying that a chest x-ray would have saved us both a lot of time. Such general observation and chats are essential and revealing even if and when technology may offer faster specific diagnoses as when one patient admitted some breathlessness on his 'second 18' (round of walking golf) but his history of a gastrectomy provoked me to do a haemoglobin which was only some 25% of normal.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Lost Art
    David Lawrence, MD |
    Radiologists have noted the decline of the physical exam for years, if not decades. It is evident from the amount of imaging that is done with findings that clearly would have been detected on a good physical exam, but not suspected.
    CONFLICT OF INTEREST: None Reported
    The Physical Exam is Not Just Diagnostic
    Ronald Dobson, MD | Retired
    The physical exam is not just diagnostic, but therapeutic for many patients as well. Humans are social animals, and touch a very important means of not only connecting with one another, but of showing empathy and concern. Think of our cousins, the chimpanzee, bonobo, and gorilla where grooming one another establishes and maintains bonds; the same applies to us. There is a “magic” conveyed in the phrase, “the laying on of hands;” by physically examining the patient, one transmits those primal, subconscious connections that help the patient believe in their healer, and we all know that patients that believe in their doctor do better.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Another nail in the coffin of the art of medicine.
    Steven Reid, M.D., F.A.A.N.S. | Doctor Lifeline
    "Now that we have the CT scanner, we don't need to take off the patient's shoes to do a Babinski." These words were spoken in jest by one of my most esteemed mentors and neurosurgical colleagues about 35 years ago. In reality, he was a great proponent of the value of the general physical examination, and the neurological examination in particular. His name was Albert Rhoton and I have no doubt his countless contributions to Neurosurgery will continue to save lives in centuries to come.

    The physical examination is second only to the patient's history in
    providing useful diagnostic information. However, it requires learning and honing skills and the ability to integrate a great deal of information -- separating the wheat from the chaff, so to speak. It requires some degree of imagination and creativity, and it's part of what makes medicine an Art. Tragically, many forces extraneous to medicine have allied to work in concert to convert medicine from an Art into a trade. Because the physical exam occurs at one point in time, and the information documented originates as subjective processes within the examiner's brain, lawyers and insurance companies consider radiology reports and laboratory tests as more reliable. Radiographic images are frozen in time and can be reinterpreted later. Same for lab tests. The mental state of a physician conducting a physical exam cannot. That doesn't decrease its value. But it does emphasize the importance of training, skill, practice, and experience.

    Insurance companies, government, bureaucrats of all stripes, and hospital administrators seek to cut costs everywhere. Training, skill, practice, and experience are costly for physicians to acquire. Why hire a skilled scientist / artist in medicine, i.e. a doctor, when a P.A. or A.R.N.P can just as easily fill the slot labelled "provider"? Doctors practice an Art. Providers practice a trade.

    The physical exam is more than tradition, it's more than ritual. It's part of the Art. We must protect the Art of Medicine, or we risk dehumanizing our field of endeavor into something resembling automotive repair. And we're quickly approaching the point of no return.

    Radiographic and lab tests have their proper place in supporting or refuting the doctor's hypothesis, the diagnosis, informed by the history and physical examination. They shouldn't be widely cast like a net to see what can be hauled in.

    Perhaps someday health care "stakeholders" will realize the value of training, skill, practice, and experience. When they do, we as doctors can save them a lot of money by focusing our expensive diagnostic technologies on the areas where they can be most useful, rather than simply following flowcharts and clicking boxes. We as physicians can be much more cost-effective than other "providers". Let us practice our Art.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    I agree!
    Joseph Siemienczuk, MD |
    This has been a pet peeve for me and unfortunately it's not new. As a third year student I recall being embarrassed and chastised by the chief of cardiology, who had invited me to listen for a gallop in a hospitalized patient. He was on the patient's right side so I approached from the left. "Never again approach a patient for exam from the left side of the bed!" Then, as an Internal Medicine resident at Cedars-Sinai I recall being impressed when we tried to stump our attending with a patient who had valve disease. He made the diagnosis before he even got to the precordium, based on peripheral pulses and neck exam. And we used to stay late to take advantage of the occasional valve disease patient who was admitted for valve replacement, in order to take advantage of the fleeting opportunity to examine a patient with a diagnosis that was dwindling in prevalence.

    Now fast forward to the modern doctor who "snakes" the stethoscope down a patient's garment, or listens through the clothing. Completely skips palpation and percussion. Ditto for the exam of lungs. And then there's two quick pokes at the abdomen, masquerading as a GI exam. Then they spend the patient's money doing an ECHO that wouldn't be needed by a decent doctor. It makes me very sad.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    It's time to adapt and not to avoid
    Sadananda Naik, MD | ALVA'S HEALTH CENTER, MOODBIDRI 574227 INDIA
    I do agree with the author. Our patients do miss the healing and supportive physical touch of their favorite doctors. But with best interest of all concerned we should move on with innovations in physical examination skills.
    CONFLICT OF INTEREST: None Reported
    Well written
    Toni Brayer, MD | SutterHealth
    The article covered all aspects of the benefits of physical exam; diagnostic, patient-centered, cost effective and honouring the art of Medicine.

    The time taken with the patient is the most important and the additional information gathered during that time. Telemedicine is a great addition to medicine but more than 1/2 of my patients still want to be seen in person when offered the choice. And with some, I insist they come in because in-person evaluation is essential for diagnosis.

    I urge young tech and test savvy doctors not to throw away their stethoscope or tuning fork.
    Internal and Family Medicine need all the tools for excellence.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Phisical Examination is a great tool
    Jorge Contarelli, Professor Infectious Dis. | University of La Plata, Argentina, School of Medicine
    I agree with Dr. Hyman! Physical examination provides crucial information about patients' diagnoses. Additionally, it helps physicians to organize their thought regarding the disease and its diagnosis. Most importantly, physical examination fosters trust between physicians and patients. Not long ago a patient's wife, whose husband had referred intense chronic pain due to post-herpetic neuralgia, thanked me for conducting a physical exam and explaining the origin of his pain, which was not critical to his health. She added that nowadays, physicians only paid minimal attention to the symptoms and dispatched patients quickly, instead of caring for the person as a whole.
    CONFLICT OF INTEREST: None Reported
    Lost Physical Exam.
    Michael Kordek, MD | Retired, Boarded in Family Medicine and CAQ in Geriatrics, graduated 1981, retired 2017.
    I agree with the author. In many cases there is no way a thorough diagnosis can be made without a physical exam. A lot depends on what you see, hear, and feel. This is especially true for incidental findings. I also use the physical exam to think, and to keep track of my review of systems (which is another lost art). Seeing something will sometimes remind you to ask something in follow or check an inconsistency. The whole model of medicine has changed and much, much has been lost. Money rules and quality disappears.
    CONFLICT OF INTEREST: None Reported
    Epiphany or coincidence?
    Liz Jenny-Avital, MD | Jacobi Medical Center; Bronx NY
    In my 30 years as an HIV primary care clinic doctor, I have always felt utterly remiss if I do not examine every patient at every encounter. Once, late one afternoon, I contemplated "cheating". Who would know? But I listened to my patient's heart and heard a new murmur. The patient had not experienced any symptoms compatible with heart disease so I let it go, but believed this was a message to never contemplate "cheating" again. The murmur really did indicate new aortic insufficiency. The cardiologist even asked when she had had endocarditis since her prior normal echo. So, a yearly echo was added to her physical exam until she disappeared. She resurfaced in another city some years later and gave her doctor my number. Another dutiful HIV provider was making sure her new heart failure was being addressed and as far as I know she got a new valve.

    So, did it really matter that I heard the murmur? She disappeared until she had symptoms of heart failure.
    She had been out of care (not the first time) due to her own stoicism or denial.

    I think we are the shamans of the body--guiding our patients into better knowledge of their bodies using the primitive tools at our disposal, and mostly, our genuine interest.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Patients Would Agree
    Philip Hansten, Professor Emeritus | University of Washington
    As a 77-year-old patient, I agree with Dr. Hyman. We patients miss regular physical exams as well. Until 4 years ago, I had an annual physical exam, but after changing health plans that has stopped. Because I am healthy, I can go long periods with no contact with a physician. It seems to me that when (not if) something does go wrong, a disorder with subtle symptoms may not be diagnosed as promptly.

    Only one quibble with Dr. Hyman's piece. Twice he mentioned demonstrating his "authority" over the patient. This is not how I see the physician-patient relationship, and
    I suspect I am not alone. I view the relationship as collaborative, with the physician making the diagnosis and recommending treatment options. It has been decades since I visited a physician who was condescending to me, and a desire to exert "authority" smacks of condescension.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Agree completely!
    Ellen Ovson, MD, IM&Addiction Med | Hospital
    The Art of Medicine requires the observation and physical examination of the patient.
    CONFLICT OF INTEREST: None Reported
    balancing art and science
    Ronald Saltzman |
    I wholeheartedly agree with the opinion that physical exam is an essential part of what we do as primary care physicians/internists/family physicians. However, I would argue that doing "annual exams" for the sake of checking a box is of little or no value. On the other hand performing a physical examination that will explain a observation; i.e. listening to the patient's lungs when they appear dyspneic is an adjunct to taking history which is the basis of where we start in evaluating not only what is going on with the patient that his been undiagnosed, but also their response to those treatments that we have rendered. Unfortunately, the move to electronic medical records has not fostered better diagnosis but rather fostered documentation, not necessarily better documentation.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    If you don't look for it, you won't find it
    Leslie Jabine, MD | University of Illinois Hospital, Chicago
    I agree with Dr. Hyman on the value of the physical exam and the need for physicians reinforce its importance, for several reasons. As one of my senior residents told me when I was a student trainee, "if you don't look for it, you won't find it"! While I agree that doctors are more than technicians and that there is an art to medicine, imagine if you were buying a new home and you told the house inspector your concerns about the foundation. They followed your concerns but completely ignored the faulty electrical system and your house later burned down. Part of our job is to alert patients to the problems they may not even be aware of. Many times as a supervising attending I have gone with residents to see patients only to be confronted with physical findings the significance of which was lost on them. I find those moments to be the most "teachable" of all. You have to "see one" before you recognize the next patient with that finding! It would be a tragedy to lose this.
    Additionally, the positive predictive value of many of our tests depends on prior probability. The physical findings should factor into this.
    Lastly, when pandemic conditions or time constraints force us to be selective about bringing patients in for direct examinations or choosing to examine/not examine in the office, we have to be extremely careful to be sure we are not affected by any biases, whether conscious or unconscious. This is a huge concern for me. Examining the patient shows you are listening to their concerns by investigating further, and in some cultures the visit may feel incomplete and disrespectful when the exam is not included.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    I agree completely
    Deborah Rich, MD | Wrentham Developmental Center
    I am a true believer in the value of the medical exam, including checking feet and pedal pulses. On many occasions a patient would tell me, as I removed his/her socks to check for foot pulses, that "no one has ever done that before." Yikes! Omitting the physical examination is not progress in medicine, regardless of all the technology.......I thank the writer for reminding us of the basics, in human touch, the doctor-patient relationship and in (old school) medical evaluation which pays big dividends in many ways........
    Deborah Rich, MD
    CONFLICT OF INTEREST: None Reported
    Primary Care Phyical Examinations
    Joel Brown, MD | University of Hawaii John A Burns School of Medicine
    I agree that the physical examination can be valuable in clinical diagnosis. However, terminology is important. What is meant by “annual” or “complete” physical exam”? A healthy, asymptomatic patient is unlikely to have abnormal findings. A head-to-toe examination takes time, which is better spent by a review of symptoms, and a social history. A better strategy is to perform a hypothesis generated examination based on symptoms or the presence of disease risk factors.
    CONFLICT OF INTEREST: None Reported
    History and Physical examination
    Wallace Hodges, MD | Providence, Seattle
    I agree with Dr. Hyman's well presented concerns.
    I'm concerned that the time pressures on physicians, particularly employed physicians, forces them to forego important aspects of the medical evaluation.
    1. EMR history templates may prompt us to ask some questions we might otherwise omit, but using the template to the exclusion of other lines of inquiry can miss important history.
    2. The checklist Review of Systems guarantees that pertinent information will be omitted. It's primary role now seems to be to pad the note to support the E&M code.
    3. A complete or directed physical exam
    is still necessary to confirm the problems/abnormalities suggested by the history. In my practice, the majority of my physical exams turn up something that I did not anticipate from the history: Nystagmus, thyromegaly, lymphadenopathy, gynecomastia, breast mass, abnormal heart valves, pleural effusion, abdominal mass, hernia, peripheral vascular disease, etc, etc. Remember Igor in "Young Frankenstein;" "Hump? What hump?"
    4. Perhaps more concerning than omissions are documentation in the record of portions of the physical examination that were not actually performed. This is hard to spot. I usually find it when I'm seeing a patient who wants a second opinion and I ask the whether certain parts of the physical exam were actually performed.
    5. Finally, when I'm completing my note, if I realize that I omitted an important question on the history or an important aspect of the physical exam, I document that in my note as "not asked" or "not examined" so that the next physician who sees the patient and reads my note will not be misled.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Physical examination and the unintended finding
    Raymond Massay, F.R.C.P.(London) | Cardiologist in private practice
    Three of the four foundation blocks of a good clinical examination depend on the physical examination. The unintended finding of the renal carcinoma as a non tender mass in the RLQ of the abdomen at a "routine" follow up of my hypertensive patient, the ovarian mass in the thyrotoxic patient referred for "a murmur", the rectal carcinoma as the cause for the anemia that caused the "Decompensated Heart Failure" in one patient, and the rapid deterioration of renal parameters in another requiring more frequent dialysis, all convince me of the indispensability of the physical examination to good clinical medicine. Not to mention its importance to the practice of medicine in resource strapped Third World countries where the new fifth block of Insonification is a very long way off. And in contemporary risk asssessment cardiology, the absence of peripheral pulses prompting the finding of carotid bruits thus chanelling the patient to an aggressive pathway of care, all spell the importance of the physical examination; long may it survive.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    "Good Faith Physical Examination"
    Gary Ordog, MD, DABEM, DABMT | County of Los Angeles, Department of Health Services, (retired)
    I agree with the author, a physical examination is a vital part of the medical workup. I have always supported 'telemedicine' as an adjunct in this process, but agree that a face to face physical examination must be done, probably on the first visit. This cannot be replaced by 'telemedicine.' I agree with the commenters that telemedicine is valuable in and of itself. For example, the physician would never see the "black mold" dripping from the walls of the patient's home, if only relying on office visits, and if not able to do telemedicine and home visits. Other than missing diagnoses, another worry I have with using only telemedicine, involves potential legal issues. Physicians' contracts with licensing boards and insurance companies require "A Good Faith Physical Examination" for each patient visit. Without this examination, the physician is considered 'negligent,' possibly 'fraudulent,' and can be subject to severe penalties. The recent pandemic has forced a new set of circumstances which the insurance and licensing contractors probably did not foresee. This will force a whole new set of licensing and contracts, to avoid calamity with physicians' business practices, until this pandemic is over, at least. Thank you.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    ×