118 Comments

I am a semi retired OB/GYN. Graduated med school in 1985. Went to a hand surgeon a couple months ago due to a small finger mass. Didn't tell anyone I was a doctor. The MA says lets get an x-ray done. I said "No" and she was not pleased. First the thing the Ortho hand specialist says before she is even completely through the door is "I heard you refused an x-ray." I said "No, not exactly, I just felt an exam should happen first. History, physical exam THEN labs and or diagnostic studies." Initially, she was perturbed, but once she realized I had a medical background and DID the exam, she said "You were right. No x-ray needed and nothing to worry about unless you have pain."

Were I not an M.D., I would have spent a lot of money on an unnecessary exam without any patient benefit. I truly detest going to doctor appointments now as they are generally not patient focused - they are income generation focused. This is a tragedy of medicine imposed by corporate medicine and time constraints. If current 'providers' are not willing to listen and exam their patients first, there is really little hope that the patient's interests are really a top priority - money and time are. coupling that with time spent concentrating on screens instead of the patient makes me very worried about being a patient. I was happy to see that someone remembered the Degown & Degown - one of the few med school books I still retain, as important , as an important part of patient care. Unfortunately, I get consults from the ED all the time requesting a GYN consult on a patient that they have not even bothered to examine. Extrapolating this to medicine in general means, unfortunately, we are all f----d. It is corporate medicine, not patient care, that drives current patient 'care' so that $$ becomes the surrogate for care.

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As medical student and a physicist, I spent several months each year overseas in lesser developed countries, repairing the only CT scanner in the country, installing a new one, the second in another. I was taught by a neurologist in central Asia how to do a comprehensive neuro exam, localize a problem to a pathway, and to a region of the brain. When we got the scanner up and running we scanned the patient and found the tumor right where he said it would be. He was as amazed by the details of the non-Contrast CT on old stuff as I was when it was right where he said it would be based on the exam. If we do not look we do not see. If we do not see, we do not know. Today as a radiation oncologist, the H&PE is still one of the more important aspects of care, from intake through treatment through follow up. I am also a heavy user of technically advanced imaging and the use of that imaging in my field. Each modality has limitations which can be offset by the other modalities. I suggest we do a better job training our residents and students in the art of a proper, directed history and physical exam.

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I gained higher appreciation of physical exam working in settings with limited to no testing immediately available. History and physical, knowledge and gestalt were key tools. Being able to ID when a patient looks “sick” (ie serious) vs stable iced mes with experience talking to and touching people. Technology is awesome but knowing and practicing basics are important. Without exam why not just have AI take over medicine?

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My first week at an outpt clinic, I had 3 pts with undiagnosed A. Fib confirmed with EKGs. I refrred them to cardiolgy. One wife asked me why it was not dignosed before. I told her I didn't know. I doubt all 3 had intermittant A fib. I heard a geronologist speak several years ago who said we need to get back to the basics. She added to listen to the heart more than a few seconds & never through clothing. I never forget what she said. I have never had a provider listen to my heart/lungs on bare sikn & never more than a few seconds. Some only listen to my lungs in 2 areas.

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I'm kind of scratching my head at your treatise. The benefit of the PE is obvious in the first case, as with one a clinician would've put shingles at the top of their differential - and would've avoided the budget-busting MRI indicated for the otherwise orthopedic possibilities.

And the benefit of the physical exam is self-evident in the other cases.

So why downplay the value of PE?

There is a lot to be said for the "laying on of hands" - temperature, moisture, and turgidity of the skin; the flinch of the patient with certain touch; the diagnostic utility of "special" orthopedic exams; the tell-tale tautness, tenderness, or borborygmi of a surgical belly; the cherry-red scream of a strep throat (with or without exudates)...the list goes on.

Your statement, "I am sure a CT (MR, Echo, PET, insert test here) could do a whole lot better."

Maybe - and cost a whole lot more.

We are all taught in our training that most diagnoses can be made with a thorough history. It can usually be confirmed with a physical exam. Additional tests should be ordered only to confirm a diagnosis, or clarify competing differentials.

Last but by no means least, a proper physical exam generates for the patient a unique bond of trust with their provider, born of careful, appropriate, and reassuring touch. Good providers have "knowing hands". Bad ones only punch keyboards.

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I wholeheartedly believe that good physical exam skills are a must. I like to examine a patient thoroughly and then order imaging and if I’m a decent physician, I should have a pretty good idea what I expect to see on the imaging. Once in a while, I am surprised, but Most of the time the presumptive diagnosis from my exam Should be in my Differential diagnosis.

I Was once consulted to see a 38 year-old woman Who had undergone lumbar laminectomy and discectomy for a bulging disc. She had failed epidurals for right leg pain, and weakness for over two years. She underwent surgery, suffered a spinal fluid leak, and was told she was “crazy” when she now reported that the other leg was also weak with pain. I am a physiatrist, and evidently they thought that also meant psychiatrist and said I needed to get her up and out of the bed. When I examined her, she was hyperreflexic 4/4 reflexes bilateral Ankles and hamstrings. I also looked at her history where she had suffered from breast cancer seven years earlier. She should’ve had lower motor neuron signs rather than upper motor, neuron signs, and an x-ray of the upper spine found that she had suffered recurrence of the breast cancer and it had gone to the thoracic spine, a thorough exam rather than just looking at an MRI of the lumbar spine and finding a bulging disc might’ve avoided this whole situation.

Also, despite efforts with AI There is no substitute for a good physical exam to guide appropriate diagnostic imaging and testing. In my opinion, Many physicians are relying too much on diagnostic testing and need to rely more on clinical exam. Just my opinion.

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I found 8 breast adenocarcinomas via palpation in patients with normal mammograms in the preceding week. Three non patients I know had similar experiences—my two sister in laws and my mother. The latter three had doctors who didn’t examine, but rather relied on mammography alone. 2/3 died.

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Resident here. While in the ED, I had a patient with GI bleed. This was an acute exacerbation of a chronic issue (going on over a year or two). I did an exam and found impressive RUSB murmur. She was admitted and an echo found severe AS, which is associated with GI Bleeds. Digging thru the chart, looks like no one ever ordered an echo or actually listened to her chest. The lesson? Tools are only as effective as the person wielding them. H+P should drive labs and imaging, not the other way around.

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I inherited a 80 yo male ( I am a PCP) from a cardiologist who retired and had gradually evolved to become his PCP and a friend.

He stated he had increasing fatigue. On exam he had severe aortic stenosis The cardiologist had gradually stopped examining the patient.

I personally am amazed at doctors who examine me through a heavy sweater.( Not under , it but on top of)

I suspect this is to check off the parts of the exam on the EMR.

I have seen the same kind of thing with diabetic pressure ulcers- fortunately the home caregiver came with to visit and mentioned it. The wife was unaware, and hard to move pt from wheelchair.

There should be handicapped accessible exam tables in every room,

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As a Independent Duty Corpsman and later as a PA I learned to do physical exams the old fashioned way. I think I still do a good exam as I often find seemingly chronic conditions like heart murmurs, sleep apnea, and scoliosis patients tell me they didn’t know they had.

I’ll admit that I don’t make most patients disrobe like we were taught. This is mostly because of time constraints, not wanting the patient to feel awkward, and lack of opposite gender chaperones.

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With all due respect, as a patient I find the attitude that the physical exam is antiquated or unnecessary to be incredibly stupid and dangerous.

I have been misdiagnosed by doctors who never bothered to perform a physical exam on me SO MANY TIMES. I have been told nothing was wrong with me when something very clearly was, and even treated as a psychiatric case instead of a medical one, because no one bothered to look at or palpate my body at all.

I've known many people who were told that imaging missed what was wrong with them, and I have often been told when asking doctors if they were sure I didn't have X, Y, or Z potential cause of my debilitating symptoms that "that wouldn't necessarily show up on imaging or the lab tests."

If you live in the United States, or for that matter in *most* countries, there's also another problem. It can be so difficult to get imaging and other tests done that many patients simply don't do it.

I've had mammograms canceled on me by hospitals at the last minute, found out the day of the appointment that an ultrasound wasn't covered by my insurance, and had to spend hours making phone calls trying to find a facility that was covered by my insurance, and then in some cases still been billed thousands of dollars for a 20-minute diagnostic procedure performed by a tech who gets paid $15 an hour because the American healthcare system is currently designed as a wealth extraction system to relocate money from patients into the portfolios of hedge funds.

Many of the Americans I know have a fear of getting diagnostic tests because they've had similar experiences. They feel it simply isn't worth it to pay thousands of dollars in the midst of an affordability crisis just because they *may* be dangerously ill. We must stop simply giving patients a cursory glance and then referring them to other facilities that might take them weeks to access or charge them months of pay when a physical exam could help us in real time.

For the love of gods, doctors, do your physical exams. And do them thoroughly and with care and skill. Lives depend on it.

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Tests are done only to confirm what you have already discovered through physical exam and a decent history.

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As a retired pulmonologist and intensivist I can assure you that good physical examinations have atrophied in the younger doctors. An excellent history is the most important piece of information we get, but a good physical exam adds to our overall assessment.

Skin cancers especially melanoma in fair skinned patients, thyroid and breast cancers, heart murmurs, abdominal aortic aneurysms, sleep apnea in short necked individuals are but a few diagnoses which can be easily diagnosed. Don’t even ask about rectals even in anemic patients in hospital.

Sad state of affairs.

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H&P are essential components tailored to pertinent complaint if any. In my experience, I have seen numerous patients who were under the care of a PCP who almost never touched them and missed vital findings including: advanced breast cancers, non-mammary Paget's; thyroid cancer; CHF; cellulitis, Gyn cancers to name a few. Early diagnosis can afford better outcomes- labs and imaging are expensive and often used without great specificity. Patients generally appreciate it when you take the time to examine them and move yourself off the laptop.

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I am a retired adult Nurse practitioner. At first appearance, my 20 yr. old patient had a small bruise over her cheek. She said she fell on a step at her mother's house, Had I not visualized her neck, I'd not have seen the ligature marks. Had I not visualized her back, I'd have missed the knife laceration over her scapula. I gently eased her into conversation and asked if the cheek bruise was related. She said they were from her "boyfriend" I suspected she was being trafficked. I called the national trafficking hotline, gave her their phone number, my card and asked if there was anything else I could do. She cried and said "no, I really need this job".After her visit with me, she went to provide a urine drug screen sample. When I inquired at the front desk about what followed, I was told she was unable to provide the sample and left with "grandpa", who brought her but didn't know her last name. Instructed to return for another try, she never did. In today's world of 20 min.visits, there is often not time for meaningful conversation. It's all there in the electronic record for us to read as we stare at a screen rather than make eye contact with a human, order tests and move on to the next patient.

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Yes, I'm old school too. You learn by examining patients, not rubber dolls. Today's students are taught to look for what falls within the two standard deviation spread. That probably works about 93% of the time. Furthermore, may times it is not a physician that determines what the exam findings will be.

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