I've been a family doctor for 19 years, caring for many of my patients for nearly that long. I am old school primary care and agree with you Adam on almost everything you write about. This one though- I have to side with Dr. Goroll. I'm a softy. Family medicine is relational medicine. Sometimes we do things because it benefits the relationship, not utilitarian medicine. I am a good steward of medical resources when it comes to labs, imaging- the things that cost my patient money and possibly unnecessary worry. A few minute physical exam? Not the same cost. My patient feels relieved that I touched them, which equals care, which equals trust. Some equations aren't logical, but must be respected anyway.
I would like to direct everyone to the TED talk by the esteemed Dr. Abraham Verghese from 2011. This is why we examine patients. Patients deserve to have at least a short, general exam, especially a new patient. I have heard stories of the melanoma on the back that the patient could not see and the doctor missed because of no exam, the afib noted in comments here, the thyroid nodule no one bothered to feel, etc. But, the real reason patients deserve an exam is to develop trust and confidence in their physician. I cannot relay how many patients I saw in my career who changed doctors because "that doctor never touched me". I admit, the PE rarely finds things not hinted at in history but lets face it- a quick exam adds a whole 5 minutes. And our patients deserve that.
On another note, as I teach residents, the more we agree with no exam the less they learn normals and will not pick up abnormals when needed. Do you want those young doctors to be your doctor one day?
My take is a lot of it could be automated. My FIT test came in the mail and the results came as well. I didn't need a doctor though since I have one his name was on it. Why could I have not had the req for standard blood draws sent to me at the appropriate age. BP can be checked at the pharmacy, weight and height don't need a Dr's visit. You could enter this in a web site or the pharmacy could collect it. From there the process could highlight people that really should see a Dr, need a prescription or more detailed tests. This would free up Dr's to help people with symptoms. This would identify more people with diabetes, high BP, high LDL.... at least compared to the current system in Canada (and I'm sure many places) waiting for the patient to think maybe I should see a doctor because I'm 40 or 50 or someone said I should.
Non American GP here. Not at all standard where I am. Seems to be a very American thing. No evidence for better outcomes. In fact, life expectancy where I am is much better than in America.
The “laying on of hands” example shows that the exam has a communication function even when its screening value is weak. Explaining what is being omitted, why, and what the visit is doing instead may help avoid unnecessary examination while reducing the feeling of dismissal.
I retired 4 years ago after a 35+ year career in Family Medicine. I am sure I did thousands of “yearly checkups” which revealed significant pathology rarely. However the visits did give me the opportunity to get to know my patients better which in turn allowed me to recognize problems later when the patient came to me because he or she just didn’t feel “quite right”. I always performed at least a basic physical exam because I believed that that there was a value in the laying of hands on the patient. Even now in retirement, when I volunteer at a free clinic, I always lay hands on the patient, no matter what the presenting problem. It helps me form a relationship with the patient and I think it makes the patient feel that he or she is valued.
As a patient I want the full experience - quite candidly, as a you man it was hard enough to get meaningful care despite my family history until I turned 50….a fact that angers me still.
So I want my full exam, my full labs, and my full 15 minutes with my trusted PC physician each year.
Don’t do a halfhearted assessment. Do it all or none.
I do not routinely recommend doing physical exams on healthy, asymptomatic adults for several reasons: Low yield of useful information, finding lab abnormalities that “require” treatment, and giving false sense of security to those with negative findings.
On the other hand, if you do believe in annual physical exams on normal patients, why just draw the labs and not examine the patient physically.
Doing just the lab without a physical exam is incomplete and inconsistent. You either believe in annual physical exams, in which case you must draw labs or you do not believe in annual exams and therefore should not order any labs. Please be consistent.
When asymptomatic patients come to me for a routine exam, I take that time to review their lifestyle and diet along with getting them off poly-pharmacy. Those 3 interventions are usually far more impactful than a physical with lab work.
Wait..... Are you saying that the fact i haven't gone in for a physical exam since my daughter was born 16 years ago is ok? (I was told that pregnancy was pretty much a 9month long physical exam anyways.)
To be honest, I'm starting to think that there is value in doing the bloodwork each year because it gives a baseline for change, especially as you go through menopause and get older. I certainly don't mind not being poked and prodded though.
I think there is an elevated perception of care if the clinician touches the patient.
I had a new patient visit with a new internist today…same clinic, new doctor…and there was no physical exam. She only talked with me. It felt odd and incomplete.
When a patient comes for tooth pain and I can clearly diagnose the problem with the radiograph, I still do the oral exam and testing of the teeth and palpation of the region. I feel it adds an important layer of thoroughness and care.
This was really interesting. I'm one of those people in my 60s who wants to check in with my PCP over little, possibly concerning, things, though not necessarily for a yearly physical. She humors me, ha-ha.
5. I agree that as a diagnostic tool a routine physical in someone without symptoms it is a poor diagnostic test- but how do I rationalize that against a woman I say several years ago where I detected a melanoma on her neck that I was able to cure with a simple excision
Is it possible that not doing routine physical exams gets doctors out of practice, and then they fail to do them in cases where they should? A young friend went to her OB and then her new PCP in the same week and complained of pounding heart, breathlessness, dizziness, exhaustion, faintness. Both doctors said they would order a cardiology consult, neither touched her, neither listened to her heart! Now, a week later, still no call from the cardiology clinic to schedule an appointment.
That may not be medical care at Dr. Cifu notes but it is becoming more and more common as we allow medical residents to think the exam is unnecessary. They are learning to consult and test. I fear this is what medical care is becoming.
“Up to date on immunizations” is a scam.
I've been a family doctor for 19 years, caring for many of my patients for nearly that long. I am old school primary care and agree with you Adam on almost everything you write about. This one though- I have to side with Dr. Goroll. I'm a softy. Family medicine is relational medicine. Sometimes we do things because it benefits the relationship, not utilitarian medicine. I am a good steward of medical resources when it comes to labs, imaging- the things that cost my patient money and possibly unnecessary worry. A few minute physical exam? Not the same cost. My patient feels relieved that I touched them, which equals care, which equals trust. Some equations aren't logical, but must be respected anyway.
With all due respect, everyone's experiences are different. Here is mine: https://kevinmd.com/2023/03/a-hands-off-approach-to-medical-exams-is-potentially-deadly.html
I would like to direct everyone to the TED talk by the esteemed Dr. Abraham Verghese from 2011. This is why we examine patients. Patients deserve to have at least a short, general exam, especially a new patient. I have heard stories of the melanoma on the back that the patient could not see and the doctor missed because of no exam, the afib noted in comments here, the thyroid nodule no one bothered to feel, etc. But, the real reason patients deserve an exam is to develop trust and confidence in their physician. I cannot relay how many patients I saw in my career who changed doctors because "that doctor never touched me". I admit, the PE rarely finds things not hinted at in history but lets face it- a quick exam adds a whole 5 minutes. And our patients deserve that.
On another note, as I teach residents, the more we agree with no exam the less they learn normals and will not pick up abnormals when needed. Do you want those young doctors to be your doctor one day?
I did read it!
My take is a lot of it could be automated. My FIT test came in the mail and the results came as well. I didn't need a doctor though since I have one his name was on it. Why could I have not had the req for standard blood draws sent to me at the appropriate age. BP can be checked at the pharmacy, weight and height don't need a Dr's visit. You could enter this in a web site or the pharmacy could collect it. From there the process could highlight people that really should see a Dr, need a prescription or more detailed tests. This would free up Dr's to help people with symptoms. This would identify more people with diabetes, high BP, high LDL.... at least compared to the current system in Canada (and I'm sure many places) waiting for the patient to think maybe I should see a doctor because I'm 40 or 50 or someone said I should.
Non American GP here. Not at all standard where I am. Seems to be a very American thing. No evidence for better outcomes. In fact, life expectancy where I am is much better than in America.
Seems grossly over rated and unnecessary to me.
The “laying on of hands” example shows that the exam has a communication function even when its screening value is weak. Explaining what is being omitted, why, and what the visit is doing instead may help avoid unnecessary examination while reducing the feeling of dismissal.
I retired 4 years ago after a 35+ year career in Family Medicine. I am sure I did thousands of “yearly checkups” which revealed significant pathology rarely. However the visits did give me the opportunity to get to know my patients better which in turn allowed me to recognize problems later when the patient came to me because he or she just didn’t feel “quite right”. I always performed at least a basic physical exam because I believed that that there was a value in the laying of hands on the patient. Even now in retirement, when I volunteer at a free clinic, I always lay hands on the patient, no matter what the presenting problem. It helps me form a relationship with the patient and I think it makes the patient feel that he or she is valued.
Agree and this is becoming a lost art of medicine. Everything is about testing and screening. You can get that without a human.
As a patient I want the full experience - quite candidly, as a you man it was hard enough to get meaningful care despite my family history until I turned 50….a fact that angers me still.
So I want my full exam, my full labs, and my full 15 minutes with my trusted PC physician each year.
Period.
Why else am I paying all this into the system??
If it's helpful it's helpful but if you just want to get your money out of the system you could ask for some random x-rays.
I've had a number of tests over the years that only made me think that was a waste of tax dollars and my time. I hope for the minimum from the system.
Don’t do a halfhearted assessment. Do it all or none.
I do not routinely recommend doing physical exams on healthy, asymptomatic adults for several reasons: Low yield of useful information, finding lab abnormalities that “require” treatment, and giving false sense of security to those with negative findings.
On the other hand, if you do believe in annual physical exams on normal patients, why just draw the labs and not examine the patient physically.
Doing just the lab without a physical exam is incomplete and inconsistent. You either believe in annual physical exams, in which case you must draw labs or you do not believe in annual exams and therefore should not order any labs. Please be consistent.
When asymptomatic patients come to me for a routine exam, I take that time to review their lifestyle and diet along with getting them off poly-pharmacy. Those 3 interventions are usually far more impactful than a physical with lab work.
Wait..... Are you saying that the fact i haven't gone in for a physical exam since my daughter was born 16 years ago is ok? (I was told that pregnancy was pretty much a 9month long physical exam anyways.)
To be honest, I'm starting to think that there is value in doing the bloodwork each year because it gives a baseline for change, especially as you go through menopause and get older. I certainly don't mind not being poked and prodded though.
I think there is an elevated perception of care if the clinician touches the patient.
I had a new patient visit with a new internist today…same clinic, new doctor…and there was no physical exam. She only talked with me. It felt odd and incomplete.
When a patient comes for tooth pain and I can clearly diagnose the problem with the radiograph, I still do the oral exam and testing of the teeth and palpation of the region. I feel it adds an important layer of thoroughness and care.
This was really interesting. I'm one of those people in my 60s who wants to check in with my PCP over little, possibly concerning, things, though not necessarily for a yearly physical. She humors me, ha-ha.
You deserve to be paired with Goroll who I have often referenced in the primary care is undervalued arena
I say do a brief physical for the following reasons
1. It establishes trust and confidence as Goroll points out
2. There is a placebo/ calming effect that I have experienced with the laying on of hands by my own family doctor
3. It does not take extra time. While I am doing the exam I can use it to provide reassurance or find out additional medical and non medical
Comment got cut off
Medical and non medical issues
4. It is ritual. Ritual is important
5. I agree that as a diagnostic tool a routine physical in someone without symptoms it is a poor diagnostic test- but how do I rationalize that against a woman I say several years ago where I detected a melanoma on her neck that I was able to cure with a simple excision
Is it possible that not doing routine physical exams gets doctors out of practice, and then they fail to do them in cases where they should? A young friend went to her OB and then her new PCP in the same week and complained of pounding heart, breathlessness, dizziness, exhaustion, faintness. Both doctors said they would order a cardiology consult, neither touched her, neither listened to her heart! Now, a week later, still no call from the cardiology clinic to schedule an appointment.
That may not be medical care at Dr. Cifu notes but it is becoming more and more common as we allow medical residents to think the exam is unnecessary. They are learning to consult and test. I fear this is what medical care is becoming.
That is not even medical care.
“I have to remind myself that the internet is not a place for thoughtful academic debate“
That is the gist