The lost art of the physical exam
The NY Times has an article about how the latest crop of doctors has forgotten—or really, never learned—how to perform a physical exam.
Oh, they can take measurements, and they can order tests. But they have come to rely on those things to diagnose a patient, rather than their eyes and ears and hands. Traditionally, those were doctors’ primary tools, and their skills in using them needed to be sharply honed. Now much of the skill seems to belong to the MRI machine and the sonogram, which give doctors a false sense of security and protection from lawsuits.
I’m not knocking those diagnostic tests; they’re important. But they should be adjuncts to a proper examination, which can tell a doctor a great deal about health rather than body parts. With an MRI and other exquisitely sensitive imaging, you can get into the trap of Too Much Information. For example, the back MRI of a person over forty without back pain often looks almost as abnormal as an MRI of one who does. What does it all mean?
One of the most impressive bits of hands-on diagnosis I’ve ever seen was performed by a man I consider a medical genius, the shoulder and elbow orthopedist Dr. Frank Jobe. The patient was my seventeen-year-old son. He had experienced multiple and repetitive shoulder dislocations, and all the doctors he’d seen on the east coast had agreed that he needed shoulder surgery of the anterior (in the front of the shoulder) type.
Dr. Jobe is the famous surgeon who invented the Tommy John elbow surgery in 1974. He’s elderly and doesn’t operate any more, but back when he saw my son he still did. He’s a genial, low-key guy, despite his fame, and he laid his hands gently on my son’s shoulder and wiggled it a little.
“Oh, my,” he said in surprise. “He’s got anterior and posterior dislocations. That’s highly unusual.”
Almost all shoulder dislocations are anterior. A few are posterior. Only a tiny percentage of shoulder dislocation patients have both, and they usually are people who have hyper-flexible connective tissue, which does not describe my son. All the doctors had missed this, except Jobe.
He went on. “And it’s the posterior dislocation that’s done the most damage.” He explained that he would do two surgeries at once, an arthroscopic one for the anterior problem, and an open surgery for the posterior. And that’s what happened (successful so far; knock wood).
But at that appointment another thing impressed me. There was a younger doctor in the room at the same time, watching. He had done the initial workup of my son and had only felt the anterior dislocation. Jobe called him over and asked him to touch my son’s shoulder again, while he showed him what he had found, “Feel this?” he asked. “Feel that little movement underneath there when I go like that?” he said, jiggling the shoulder ever so slightly. “That’s it.”
The younger doctor tried and tried, but he shook his head. He couldn’t feel it.
I had my own experience with Dr. Jobe. By the time I had my elbow surgery for an ulnar nerve problem, about a decade ago, Dr. Jobe was phasing out the surgical part of his life. I had been to countless doctors, almost all of whom had pronounced my case impossible to diagnose, because the EMG findings (that’s an electrical test for nerve conduction) were ambiguous. So I went back to Los Angeles and Dr. Jobe.
He studied all the findings; I had about eight sets of EMGs to show him. He did his own exam. And in the end he said he thought I was a candidate for surgery. “I can’t give you a guarantee,” he said. “But despite what the EMGs say, I think that, from your symptoms and my examination, this surgery will help you.”
And so it did, rather dramatically, although it took a few years for me to recover. Jobe assisted at my surgery, and I was very glad he did, because it turned out that my case was unusually complex.
I still remember what Dr. Jobe said to me in the recovery room, “We were surprised at how much damage we saw when we opened you up. Your ulnar nerve was very inflamed, and it was pinned down by a large amount of scar tissue that we had to dissect off the nerve. Other nerves had been recruited into the mess, and we had to sever them. Then we moved the ulnar nerve the way we usually do. I can’t guarantee what will happen or how long it will take to heal, because your case is unusual, but I will tell you this: you needed this surgery. Without it, you were never going to get better.”
Without Jobe and his skills, I probably would never have been able to have had that surgery, and I wonder what would have happened to me. And I wonder whether he’s been able to pass those skills on to a significant number of doctors. And I wonder whether they are able to take the time and trouble to use them. I certainly hope so.
I happened to get a posterior shoulder dislocation in a remote tundra site after fall with a heavy backpack on rail. It took hours to get a medical help, but the surgeon did excelent job by manually putting the shoulder bone in place. The next day I was capable to ski, admittedly, with a lighter backpack and using only one arm for two week tundra crossing. But when I returned to Moscow, I found than every second day my shoulder get dislocated again, mercifully, for several minutes only, before spontaneously clicking in place. I was told that only surgery can fix it.
But my friend found that rare kind of “witch doctor” – a manual therapist, or as they were called in peasant villages, “bonesetter”. He said that the condition is curable by several dozen massage sessions. And he was right! This was four decades ago, and I never had my shoulder dislocated since then.
Neo,
You may be correct about such physician’s being a dying breed. I am a 3 time cancer survivor, and owe each survival to gifted physicians with a hand’s on approach.
To lose what is literally a personal touch will make the profession much more bureaucratic and sterile.
Sergey: amazing story.
My diagnosis story comes from Mexico City. While I was crossing a street a car knocked me down, resulting in pain in a shoulder. Of course, the car didn’t stop. After finishing my errand, I got on the subway and asked for directions to the National Medical College. I got there in 10 minutes. I soon found a clinic, and within several minutes of arriving at the clinic, an MD saw me. No paperwork.
There was no X-ray. The MD asked if I could raise the arm that hurt. I could and did. He told me that I would be fine, and that was the end of the exam.
Within a week, the pain had gone.
In the US, there would have been oodles of paperwork and X rays. The MD in Mexico City had enough experience to know that if one could raise the arm, there wasn’t a break.
It’s hard enough to find an auto mechanic who can repair the much simpler mechanisms in a car.
To find a physician who can properly diagnose a problem in a living machine with a touch is a miracle.
Some things can’t be taught.
Neo,
Had you been in a government health care system you would not have had the opportunity to try multiple doctors for you or your son. It would be simply luck of the draw.
I was a corpsman during the Vietnam War era, and since I often worked night shifts at the dispensaries, emergency rooms, and hospitals where I worked, I had a lot of time to read the medical textbooks in their libraries and to observe examinations, and I was always conscious of the fact that, from what I had read, all sorts of clues can be found by careful observation during an exam, clues that I have since observed in my own experience with doctors are today–it seems– rarely even looked for.
I notice for instance, that in some cases doctors–good doctors, too–will sometimes not even listen to your chest, and, if they do, frequently do so hurriedly and through several layers of clothes. Having listed to a few hearts and chests myself, I believe that what you hear through clothing is very inferior to and conveys much less information than what you will hear when the stethoscope is placed on bare skin.
One of my legs is considerably shorter than the other, and I sometimes have a slight limp that gets noticeably more pronounced when I am tired, yet, not one doctor I have ever consulted has ever noticed this, I have always had to mention this to them to get it into the record. I will say that once a chiropractor that was recommended to me was able to fix back pain problems caused by the muscle imbalances this mismatch in leg length caused by, first, taking very careful X-rays and measurements, then embarking on an intensive course of manipulations followed by custom orthotics and a wedge in the shoe on the short leg, to make up the difference in leg length–far more thought, planning, effort and work than I have ever experienced a regular doctor putting in.
Then, there are hands and fingernails. For instance, the hands of people with heart problems often have enlarged, clubbed finger ends, and the effects of vitamin deficiencies can show up in how fingernails are formed and appear, yet, in the routine exams I have experienced over the decades, I have rarely had a doctor actually look closely at my hands, and certainly not at my fingernails.
So, I do agree that the physical exam–a source of many significant clues if done property and thoroughly–is becoming a dying art.
It is, as guy points out, a trans-occupational deficit.
In medicine, we have surrendered to technology the marvelous skills that can indeed be learned by pretty much anyone properly mentored, given enough effort. Therein lies the shortage. There are very very few young MDs today that have ever heard the faint, low-pitch diastolic rumble and opening snap of mitral stenosis in a human; a recording, amplified, instead. If it’s cardiac, get an EKG and an Echo and read the reports instead of learning how to listen to that marvelous organ. What if you can’t get an Echo? Well, duuhh, I don’t know….(of course, rheumatic heart disease is today much less common).
But think of it: the stethoscope was invented 200 years ago, and the Littman scope, perfected in the 1960s, is now largely a badge of office, inappropriately draped around countless necks. Irritating.
My younger son saw a neurologist several years ago who never laid a hand on him, despite the fact that MD dad was in the room. He’d had his MRI, you see.
So tell us, Neo, after Dr. Jobe worked on you, how long did it take to recover the velocity on your fast ball?
Alex Bensky: I’m still waiting.
And I can’t play the violin, either. Bummer.
So tell us, Neo, after Dr. Jobe worked on you, how long did it take to recover the velocity on your fast ball?
Ah, Alex, you beat me to it. I was going to ask neo if she could once again bring the heat!
Wolla Dolbo, as a youth I was fascinated that Arthur Conan Doyle took his inspiration for Sherlock Holmes’s powers of observation and deduction from Joseph Bell, with whom (IIRC) he trained as a physician.
No MRIs, needless to say. I suspect that a driver for diagnostic imaging is defensive medicine: what one heard with a stethoscope years earlier is intangible, but what one could see on a diagnostic imaging scan is not.
I’ve had one doctor in the last thirty years who gave a thorough physical examination. He was very good, carefully examined my feet, hands, palpated, etc. I think he could tell a lot just from observation. Unfortunately he developed a brain tumor, self diagnosed, and passed away some years ago. The doctors I’ve had since then mostly go by the tests and write prescriptions. I can’t figure out if I am really getting the exam I’m paying for, but I suspect something is missing.
Chiming in: I last had a good diagnostician at the Beekman Downtown Hospital in NYC when I had chest pains (heart attack? no, panic attack). He really loved his job: was a veritable Sherlock and lived for the oddball discovery. Wrote a column for Discover Magazine. Dr. Tony Dajer: google him for some fascinating case reports.
For the last three years, my fingernails have suddenly become very brittle and developed the pincer-nail formation. Now my big toenails are lifting off the nailbed in the center of the toe. And they’re badly ingrown, for the first time in my life. I wear comfy tennis shoes, not heels (never did, really). I’ve always had healthy, normal-shaped nails, so what’s going on? Haven’t made any radical changes in diet, but I have taken some vitamin supplements.
But I can’t get the podiatrist or my GP to take the slightest interest in this phenomenon (I’m just 50, BTW).
Here’s a sample of Dr. Dajer’s work:
http://www.freerepublic.com/focus/f-news/1813327/posts
He’s a medical detective like Dr. House — but without the acidulous attitude (really a nice man, actually).
Overconfidence about diagnostic scanners and tests often produces mistakes. Several years ago I got a pneumonia and had to have many fluorographies, X-ray examinations and so on. But while my primary care doctor was deadly sure I had a pneumonia, hearing my breath with usial stetoscope, there were no sign of it in all these images taken by sophisticated machines. And he simply directed me to a lung sanatorium for a month.
Beverly, this can be a fungus of some sort. There are many kinds of them, and not all manifest themselves with discoloration or other obvious symptoms. But brittleness and deformation are always present. Detachment from nail bed is especially telling. Try some anti-fungi antibiotic in form of nail laquer.
Neo,
Do you suspect you were very, very naughty in a previous life?
You have a much better chance to be examined, really examined, with time and attention spent, by a surgeon or a cardiologist or an oncologist than a regular GP or someone with less dramatic specialization (dermatologist, for example, or what they call “a pain specialist”).
Because monetary gain to a Dr. from a surgery – if you’re prescribed one – is much grater than a one or even 5 visits to a GP.
Did oyu notice how much time a GP spends with you and what he/she does during the visit?
You come 1/2hr before your appointed time, wait for an hour in teh reception, then the nurse calls you into exam room, gives you a rag to change into, measures your BP, height and weight, sometimes makes you go for a urinal test. Mind you, she doesn’t ask about your symptoms or of you opinion to receive these tests (and they are tests, because your insurance or you will pay $200 for it.)
You wait, in cold A/C room with scary instruments and posters for another 1/2 hr, then The Doctor Himself comes, spends about 30 sec asking you the reason for your visit, looks at your chart, spends another 30 sec working the stethoscope through 5 layers of clothing, does other “magic” visual observation for another minute, then asks where is your tests results. If you have them, he’s spend 5 minutes reading the numbers (that laboratory helpfully juxtaposed against acceptable range), and declare the diagnosis.
He will not listen to your descriptions of your condition (they call it “complain”…), you trying to bring his attention to various pains you have. No, he already knows, and knows better. He’s ready with 2 prescriptions and demand to come again in a month. Then, when you tell him you felt worse, he increases the dose of medication and tells you to come in another month. You do, dragging your feet, doped and aching all over, and he prescribes you another medicine, or even 5 – to compensate for side effects of the first two.
And all these time you receive bills: $400 – initial consultations, $500 – first round of test, $800 -second. Sometimes the good doctor even tells you to what lab he sends you – he says he prefers them. SO what if you then discover the lab is not in your insurance network – doctor is “above” such soiled matters as money, he doesn’t want to talk about it; he sends you to his assistants to discuss your payments. And all the while, after months of going back and forth, and spending loads, you feel worse and worse.
What business, other than medical office, would operate like that without losing customers? Not for one minute and nobody.
I had a conversation with my doctor during the last visit.
I: My symptoms are the same and some are worse.
She, in offended tone: But your tests show big improvement! You can’t be feeling the same.
I: but I do
She: OK, we’ll increase the dose. On Sundays oyu’ll take two pills instead of one. Good bye!
Tatyana, you have just described *exactly* my experience with modern medicine.
When I was growing up, we had a GP for our family who was like an old country doctor. She knew all of our family, knew our histories, our hobbies and our life situations, and chatted with us at every visit, making sure that she was up to date on what was going on with us. Unfortunately she retired just after I left for college. She was one of the last of a dying breed. The doctor I have now, I see him about once every six months for maybe five minutes at a time, and barely get a chance to ask him any questions about anything. He has no clue what’s going on with my life in any way, and I am certain wouldn’t recognize me if I passed him on the street. And again, this is only going to get worse under socialized medicine. 😛
I have a GP like this, that I continue to go to despite the fact that he is often out of network. He is a Seventh Day Adventist and he is Arthur Gaskell III in Camas, WA.
My late husband did not like doctors but he liked and respected Dr. Gaskell. I felt terrible that I could not get him to go to the doctor when he came down with the pneumonia that killed him. A few months after his death, I went in for a checkup. I told him how much my husband had respected him and I broke down. He put his arms around me and held me for a minute, then said a prayer out loud over me. I do not think I want to live in a society where a doctor could not perform such a simple act of kindness.
Last checkup, he prescribed vitamin D for me (which the insurance didn’t cover, of course.) I don’t know how much longer he will practice or what I will do when he is gone, but I am grateful that such doctors still exist.
*colagirl – and my doctor has been practicing for over 20 years!
She is not the worse I’ve had, and sometimes I can make her listen – but her reception really resembles conveyor. 4 patient rooms, occupied at all times, and doctor circulating between them seeing…i don’t know, maybe 30-40 patients a day? Yeah, I know – those loans and insurance premiums had to be paid, but why am I used for a milking cow?
I’m not saying there are no attentive doctors – in fact, I did have fairly recently a rather positive experience with an ophthalmologist when I went through LASIK: but I paid for operations out of pocket. Maybe that’s the key?
Or, to be more precise: a good doctor will be even better if you pay him directly, but noting will fix a bad one…
Nolanimrod: well, if so, I hope I at least had a good time.
A woman, Dr. Lorna Stuart, in my church founded a clinic for the uninsured in nearby Phoenixville, PA, called The Clinic (it’s been written up a lot lately). Dr. Stuart can be a little grating in person because she’s so darn BRILLIANT and opinionated (and hesitates not one bit to share her opinions) – but she is first and foremost a superb diagnostician. She learned medicine (after taking a Ph.D.) in British Columbia, where apparently things were very hands-on. And it’s a good thing she’s so great at diagnosing people’s complaints, because in her clinic, they have some imaging equipment but not everything out there.
Her opinions that bug me have to do with availability of medical care for the poor; she says she’s apolitical but simply wants no one to have to choose between groceries and taking a sick child to the doctor – which in practice comes down to strong support for single-payer health care. But in listening to her give a talk just this week, it struck me that what she really wants is radical reform in medical malpractice, so that doctors could go back to diagnosing most things with their eyes, ears, hands, noses, etc.
In my early geology days, we learned all kinds of field tests for various minerals (including licking rock cores to see if they contained halite – salt – or sylvite – potassium chloride. We were also advised by one textbook that “licking miles of core” would be a really unpleasant task, so we could also use our trusty pocketknives to tell the difference between these closely related minerals, one of which “parts” smoothly when scored with a knife, and the other of which breaks in a brittle fashion). I wonder if they still teach those tests today, or if it’s all about examining rocks in thin section (which is a b*tch!) or sending them in for chemical analysis. My first post-college job was sitting on a drill rig, looking at the sand-sized particles of rock that came out of the hole during drilling and determining which formation we were drilling in by making an almost totally visual judgment about what each grain of sand was and what percentage of grains were what. Clear as the drilling mud we washed off those grains, I know, but chalk it up to the beer I just finished…
Occam @8:30 pm:
You are right.
We have not only gotten dependent on technology, technology fills so many functions that our own faculties can’t but atrophy.
Take math, for example. People used to do things in their heads, with the abacus acting as a time-saving and error-checking device, but leaving most of the things for the human (the “computer” until about 30 years ago) to do.
Then came the slide rule and saved humans the more complex and error-prone stuff, like multiplication, division, squares, cubes, roots, sines and tangents. But the slide rule still left humans the basic skill of mental math: It couldn’t do addition or subtraction, and it gave a result to which the human had to work out the exponent (for instance, the cube of 16 got out as 1.6³ ≈ 4.1, and the human had to work out the answer as near to 4100, actually 4096). Estimation and mental math were essential in those days as before.
The electronic calculator with its sure and fixed answers did away with all that. So kids today whip out their calculators for the simplest multiplication, and they don’t care about fudge-fingering the buttons – “My calculator says that’s the answer!”
But wait, that isn’t the end of it! Graphing and programmable calculators took even more of the human’s load, and now, finally, we have packages like Mathematica and Wolfram that can work out your questions Google-style. In fact, their producers boast that you don’t need a deep mathematical background to work them. If anyone protests, their answer is: “We’re doing to the plain scientific calculator what the same did to the slide rule.”
Today, no one but the old-timers have that intuitive feel, gained through experience and ensured by the lack of devices that hold your hands, for numbers, calculations and what the results should be like. This trend of dependency on more and more advanced technology is what mathematicians, doctors, auto mechanics and a lot of other professionals now suffer from. Old tech made new tech possible, then new tech pushed the skills of old tech away like a stage rocket booster.
Jim Packard
(also known as Conservigilant)
“Usually what happens is that the doctor will ask for a suite of biochemical tests–liver fat, pancreas function, and so on,” she tells me. “The tests could turn up something, but they’re probably irrelevant. Just having a good talk with the patient and getting a close history is much more likely to tell me what’s wrong.” Of course, the doctors have all been trained to order these tests, she notes, and doing so is a lot quicker than a long bedside chat.
Lies, Damned Lies, and Medical Science
The most attentive and best experience with a medical professional I’ve had recently has been with my old dentist. My roommate recommended him to me when I needed a root canal. He was another old-timer who may not have had all the flashy medical equipment (when I had to go to a new, different dentist, this dentist said the root canal procedure I’d had done had been done in an old-fashioned way) but he really *listened* to me, took the time to pay attention to what was going on in my life, carefully explained everything and made sure I understood, and actually offered me *choices* on how to proceed with my treatment.
Compare and contrast to the new dentist I had to go to, a guy just out of dental school with an office full of high-tech equipment: he patronized me, barely listened to anything I had to say, and insisted I needed things fixed that hadn’t been causing me any problems at all. I went to this guy *once,* then decided I was willing to drive an hour and pay out-of-network costs to go back to the guy I’d had before. Now, unfortunately, I’ve moved three hours away from him and I’m not sure how to find a good dentist where I live now. *sigh*
What insurance did you have or did you pay out of pocket? I can’t imagine a quality doctor such as this would’ve been on some common HMO plan.
Hong: at the time, I believe I had Anthem (it’s a while back). I had a policy that didn’t make me go through a primary physician’s recommendation. I could go anywhere in the country, geographically.
I have always made sure I have policies that don’t tie me into one region. There wasn’t a decent elbow surgeon in Boston, for example, who I went to (and I went to quite a few) who was willing to operate on me. They all dismissed me because my EMGs were ambiguous, even though I had plenty of symptoms that pointed to ulnar nerve compression at the elbow. They insisted that the tests show it unequivocally before they would operate.
If I hadn’t found Jobe, I think I would have remained in extremely serious pain and quite disabled for life.