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Has the Art of Touch (PE) been Superannuated by Technology?


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This is a question for new graduates as well as us old timers. When I was in PA school, we had a very good course on the art of the history and physical exam (taught by Glen Combs). It was emphasized with use, that our sight, touch, smell, and feel, using nothing more than our eyes, pocket scopes was how we make a diagnosis and labs, X ray, (we didn't have MRI or good US) only confirmed what we had figured out. We measured organs with percussion and a tape measure, etc. We knew what each heart valve was doing, or not doing by auscultation.

I have the sense that young doctors (haven't observed PAs so much) have lost that art. They ask a few questions, barely touch you and if they do, it's through clothes are even blankets, and then go off and order a bunch of tests.

What do you think? Is the art of the good history and excellent PE is being lost or is it still a key part of PA training?

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With the 2021 E&M guidelines I can get a 99205 with a 10 minute interview and 50 minutes reviewing records and charting, no VS, no physical exam required.

It's actually perversely freeing to only have to document what is actually significant in order to be compensated for the work I do. But yeah, if you don't have to do it to get paid? Lots of things are going by the wayside.

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In my practice I'd say I do both, but do depend more on imaging, EKG, and diagnostic tests.  I do spend a fair bit of time on the HPI.  There is definitely a loss of skill on the PE, but I'm not sure that leads to a poorer overall workup.  For example, many abdominal physical exams aren't conclusive.  Using imaging, I've found many appy's on patients that had minimal tenderness on exam and/or tenderness that wasn't localized to the RLQ.  Beside U/S tells more than can be found just auscultation and palpation in many cases, not just abdomens.

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Here’s a counter-point, not necessarily because I have strong opinions but because it’s a worthwhile discussion: what value does the physical exam actually bring?

One of my MD practice partners has been working on the concept of the “evidence-based physical exam,” and I’ve found it fascinating. It’s actually something of a return to the core Osler kind of point of view. History-taking should get you most of the way to any diagnosis, or so goes the theory, and any physical exam (or blood work, or imaging) should ideally be something you do to confirm the things you’re pretty sure you know, from talking and listening carefully. So much of what we do is very low in sensitivity and specificity. Most of the time, an exam finding is just something we use to reinforce the need for some other test, so our own bias about how important that test will be is what determines how we describe that finding. It’s art, not science.

Now, obviously, there is value in the ritual and the tradition of laying hands on the patient, and there’s a kind of therapeutic touch aspect, in which people feel like they have been listened to and respected because of the attention that’s been paid. Lots of what we do provides important reassurance like that. So I’d never say there isn’t value in a physical exam. I do think it’s worth asking, how much of that value is truly diagnostic? 

This gets especially interesting for me, since my undergrad degree was in Theatre. I wore a long white coat when I was working Urgent Care, for purely presentational reasons. And it helped. As my beard has gotten whiter, my perceived expertise has increased even as I’ve been less connected to medical podcasts and the latest updates and developments. 

Telemedicine has given a lot of opportunities to test how necessary physical exam really is. Sure, there are things that can’t be done without a PE. I found an abdominal hernia in one recent patient, and another had a foreign body in an ear canal. Office visits will never go away. But there was the guy I led through a series of “Simon Says” type shoulder maneuvers, explaining as we went that we could tell frozen shoulder from biceps tendinitis from a full-thickness RC tear. And there have been so many people who say “thank you for explaining that” or “thanks for your time today.” 

TL;DR - physical exam is important, but I don’t think it’s all that important for reasons of diagnostic accuracy. It’s often most important as theatre, in fact. 

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Agree with above. The thoroughly detailed physical exam, chock full of eponymous "signs" truly dates from a time when we either didn't have access to advanced imaging equipment (or it wasn't invented yet).

What the sensitivity/specificity of Homan's sign for DVT? Rovsing for appendicitis? When was the last time you accurately performed whispered pectoriloquy or tactile vocal fremitus and diagnosed a PNA/effusion? 

There is definite benefit in the laying of hands on a patient, but the majority of that benefit comes from the relationship established in my mind, or at least in determining what my next step is to actually diagnose the underlying condition.

And at my program at least, they were all still taught in exhausting 50-100+ step exams.

*Excluding heart tones and lung sounds, I'll hold on to those until the day I die.

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I have not seen the 2021 E&M guidelines, but if that is the way they are written, then it will be the death of the full exam. Money and time-saving, always trumps.

I'm not saying that is a bad thing (although it doesn't feel good to me) but the question stands if this is good for medicine? Is the hands-on exam superfluous? What about, as mentioned, the human aspect of face to face time and touch? Are we heading to a Dr. Jones on Star Trek medicine, a hand-held device that does a full body scan and finds any abnormal state and not touching required?

I'm a great believer in the convenience of telemedicine and relied on it heavily when I had my headache clinic. But never in lieu of a needed hands on exam.

I am sure we can all tell stories where our hands-on exam was telling us that our patient was fine, but then some test showed that they had a serious problem, and the reverse. I can think of dozens of my own stories. But here's one that stuck with me.

I was working the ED. A mother brought a child in (I think he was about eight). The front desk checked him in and the MA did the vitals. His vitals were normal, temp of 98.6. His mother said up front (diagnosis by proxy) that he had a terrible headache, one of his typical migraines. She  has them too.

Since migraine was the crux of my day job, I always took acute headaches seriously and did a full hands on exam. Mother just wanted a "pain shot" which I would not have done anyway.

But doing my exam, I found a child that was in no distress but uncomfortable. But when I placed my hand on his forehead to do my ophthalmologic exam, his head felt hot. I looked as his recorded temperature and it was 98.6 F, I went up to the check in area and got a glass thermometer. I checked his oral temperature again, and it was 103F. I was first worried about meningitis. To make a long story short, this took me down a far more serious path. With a closer exam, his lids were slightly redden and swollen AND painful with movement of his right eye. SO (fill in the blank) was confirmed with a CBC and CT.

My point being, with the mother's leading comments, I could have dismissed this child as migraine if I had not touched him. I also had a chat with the MA who didn't seem to take his job that seriously.

 

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I think PA schools tend to emphasize these skills much more than other healthcare providers, and it is great to have more tools in the kit. We're a little spoiled in most areas of this country. I've had the opportunity to see medicine overseas in an austere environment and it was eye opening to see what people could diagnose with a good history and exam.

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I'll be honest--I have a Butterfly iQ.  If I have a choice between listening with a stethoscope and slapping some gel on the patient and taking a look under the hood, which one am I going to choose?  Ignore the fact that I can bill for a limited ultrasound exam with the second tool: POCUS is just far cooler.

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10 hours ago, jmj11 said:

I am sure we can all tell stories where our hands-on exam was telling us that our patient was fine, but then some test showed that they had a serious problem, and the reverse. I can think of dozens of my own stories. But here's one that stuck with me.

Agreed.  Sometimes something on the PE raises the "this isn't right flag".  More often, I find those on the HPI.  The one that sticks in my mind was a chest pain bounce back.  She'd had a negative chest pain workup in our ED the day before.  When I saw her she said something about how the pain started in her chest and then went up into her neck and down.  STAT CTA chest/abd/pelvis showed dissection from ascending aorta through iliacs with pericardial effusion. Only good thing about the case is that got her a helicopter so she could die in the OR at our tertiary referral center instead of in the ED in my critical access hospital. Maybe there was some physical exam finding that would have identified this, but none comes to mind.  I'm grateful I practice in a time where I can describe what's going on better to my consultants.

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13 hours ago, ohiovolffemtp said:

Maybe there was some physical exam finding that would have identified this, but none comes to mind.  I'm grateful I practice in a time where I can describe what's going on better to my consultants.

Varying contralateral pulses? Dissections are brutal.

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23 minutes ago, rev ronin said:

If you take them always on chest pain, sure.  But after the history as reported, that's just a confirmatory finding to support the diagnosis made by history, which was pretty darn pathognomic as reported by @ohiovolffemtp.

Apparently the day before it wasn't in the history, either the dissection hadn't extended to that point, the question wasn't asked, or the clinician missed it. This was a bounce back remember.

And you don't take them on chest pain? It takes like 5 seconds.

Edit: That Butterfly would've been nice!

Edited by MediMike
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37 minutes ago, MediMike said:

Apparently the day before it wasn't in the history, either the dissection hadn't extended to that point, the question wasn't asked, or the clinician missed it. This was a bounce back remember.

And you don't take them on chest pain? It takes like 5 seconds.

Edit: That Butterfly would've been nice!

I should, but honestly I'm reaching for the phone and EKG first in an UC setting, and I would probably not have run out of other things to do before the ALS unit got there.  Absolutely a good reminder to do so.

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2 hours ago, rev ronin said:

I should, but honestly I'm reaching for the phone and EKG first in an UC setting, and I would probably not have run out of other things to do before the ALS unit got there.  Absolutely a good reminder to do so.

Dangit.  Apparently there's a limit to the # of "likes" that you can give per day?

Makes total sense and if you're not in a triage situation or definitive management one making that decision to send home vs stay for further work up I totally get it.

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TVF/WP 2 years ago in a suspected PNA since I didn’t have CXR capability.  Both positive in an influenza pt.  CXR through PCP later confirmed.  Another case I was first IM/specialty PA at large med center in DFW and IM docs were not happy that I was taking their consulting/H&P gig.  IM doc asked if I could check a pt. that was unresponsive and was “ill” while they were off doing something else (must’ve been a consultant on one of their patients though I was Card).  Positive Murphy’s with grimacing though non-verbalizing.  Yep, had cholelithiasis/cystitis.  IM section was more tolerant of me after that.

Edited by GetMeOuttaThisMess
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Here is a prehistoric reply. I practiced in the Golden age of medicine and I would classify today as the Bronze age. I am a firm believer in a good H&P and I did my surgical exam's using the techniques that I learned from Cope's Examination of the Abdomen. I believe in touch, palpation, percussion, auscultation and carefully listening to my pulses and cardiac information. I always would examine the aorta of a person who had hypertension and complained of chest pain, abdominal pain and pain that radiated to the back. A clinician does not get a second chance on an aneurysm. Personally, although it is vogue and a cash cow, I despise telemedicine except for primary care, psyche and a few others where I would depend mainly on conversation. Yes, I know there are all sorts of apps that can help a clinician and that there is a pandemic going on but the art of a physical exam has been blown off the aircraft carrier.

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2 hours ago, surgblumm said:

Here is a prehistoric reply. I practiced in the Golden age of medicine and I would classify today as the Bronze age. I am a firm believer in a good H&P and I did my surgical exam's using the techniques that I learned from Cope's Examination of the Abdomen. I believe in touch, palpation, percussion, auscultation and carefully listening to my pulses and cardiac information. I always would examine the aorta of a person who had hypertension and complained of chest pain, abdominal pain and pain that radiated to the back. A clinician does not get a second chance on an aneurysm. Personally, although it is vogue and a cash cow, I despise telemedicine except for primary care, psyche and a few others where I would depend mainly on conversation. Yes, I know there are all sorts of apps that can help a clinician and that there is a pandemic going on but the art of a physical exam has been blown off the aircraft carrier.

If you find nothing on your exam in a patient whose history otherwise sounds like a dissection/AAA are you not still going to obtain imaging? Think that's the crux of it

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15 hours ago, MediMike said:

f you find nothing on your exam in a patient whose history otherwise sounds like a dissection/AAA are you not still going to obtain imaging? Think that's the crux of it

From the EM point of view, ie ROBS - Rule Out Bad S...., from the feedback I get on chart review, abdominal imaging is considered the standard of care.  This seems to be even more the case the older the patient is.  For example, 70+ it seems is expected to get a CT for nearly all abdominal complaints.  Adolescents - not so much.  However, even with them if the HPI is suspicious or body habitus prevents good physical exam, CT is indicated.  It seems with heads HPI & PE can do a better job reducing the need for imaging.  Chests fall somewhere in the middle as HPI, PE, and plain films can tell much more.

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2 hours ago, ohiovolffemtp said:

From the EM point of view, ie ROBS - Rule Out Bad S...., from the feedback I get on chart review, abdominal imaging is considered the standard of care.  This seems to be even more the case the older the patient is.  For example, 70+ it seems is expected to get a CT for nearly all abdominal complaints.  Adolescents - not so much.  However, even with them if the HPI is suspicious or body habitus prevents good physical exam, CT is indicated.  It seems with heads HPI & PE can do a better job reducing the need for imaging.  Chests fall somewhere in the middle as HPI, PE, and plain films can tell much more.

Had a radiologist years ago when I was in the ED say that he had never seen an appy have stool at the ICJ on plain film due to the inflammatory changes.  I still like the idea of BS U/S and if appy can be visualized and appears normal then CT can wait.  No visualized appy?  CT.

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2 hours ago, ohiovolffemtp said:

Cincinnati Children's is big on U/S for appy's.  I'm not good enough at bedside U/S to find appy's, especially on plus size adults.  For me, CT is the go to - and for pretty much every ED provider: doc, PA, NP that I've worked with.

I have never found an appendix, either.  But then, I've never actually had the opportunity to go try and find a suspected angry appy.

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