Wednesday, October 8, 2014

To Examine or Not to Examine That Is the Question


I just read an article in JAMA[1] questioning the need for routine physical examination on a healthy patient as there is no "evidence" to support this. The author then presents an anecdote regarding his own father who on a routine physical examination was thought to have enlarged aorta by palpation: leading to an ultrasound showing a normal aorta but question of a pancreatic mass; leading to a CT scan showing a , of course, normal pancreas but a possible liver lesion; leading to a biopsy (of a hemangioma); leading to a hemorrhage; and , finally, the denouement, leading  to a stay in an ICU. Cost: $50,000. Admittedly, the author is trying to pick a bone with routine yearly physical examinations but the article gives impression that examination of a "healthy" organ is worse than useless and calls into question the usefulness of any physical examination.

Since we are in the realm of anecdote let me present a few. In my career, I have picked up on routine examination six or seven abdominal aortic aneurysms of significant size. All of these patients were smokers and had a bruit. My yield on this physical finding is about 80%. I suspect the author's father's internist had never palpated an actual aneurysm. When I taught in a medical school, I told my students and residents that the key to physical examination is not to be Dr. Joseph Bell[2] but just to do it. In other words, the key is to look for the obvious not the subtle.[3] Unfortunately fear of lawsuits has made all of us order tests for insignificant findings.

To continue: in the past few months I saw patient for consultation regarding his prostate cancer and noticed he was jaundiced. The workup revealed cholelithiasis leading to cholecystectomy. Thus, probably preventing a visit to the emergency room, an admission, and a possible emergency cholecystectomy. One of my partners saw patient in almost the exact same circumstances except that patient had mass in the head of the pancreas, leading to a successful Whipple procedure with negative margins and no evidence of lymphatic or other metastases. One year ago, I saw patient on a routine follow-up for prostate cancer and, on a routine physical examination, I discovered bilateral axillary lymphadenopathy: non-Hodgkin's lymphoma, successfully treated. I can continue but enough already.

My great fear is with the deemphasis on physical examination future physicians will not know how to do it, for this skill  requires repeated examinations of many normal patients. I am afraid my fear has become reality. The past few years I have seen six or seven patients with palpable supraclavicular lymphadenopathy who were about to undergo either a bone biopsy or a lung biopsy. We (the medical team) in most cases were able to substitute a far less invasive procedure with a higher yield, namely, a core biopsy of palpable lymph node. Another patient that I was following for head-and-neck cancer came in and complained of chest pain which had resulted a visit to the emergency room the day before. The patient had undergone an EKG, laboratory examinations, a stress test, and a cardiac catheterization all of which were negative. Who knows what that cost. I then asked the patient a few simple questions such as how long he had the pain, have you ever had a pain like this before, does it go anywhere to another part of the body, etc. I then pushed on the patient's costochondral junction and she jumped: diagnosis, costochondritis. A thirty second physical examination made the diagnosis better and quicker thousands of dollars of  tests with much less risk to the patient.

As the hand becomes less used, the connection to the brain goes. This, I am afraid, is becoming rampant among academic physicians. Consider this vignette in the New England Journal of Medicine: "A 59-year-old schoolteacher, awoke on September 8, 2009, with facial paralysis. In a local emergency room, she underwent computed tomographic and magnetic resonance imaging brain scanning. The scans were normal, Bell's palsy was diagnosed, and the symptoms resolved over the next few weeks. Two weeks later, (the patient) began losing her hair in a band like distribution...(followed shortly thereafter by) fatigue, malaise, memory loss, and confusion."[4] Investigation revealed the patient had received therapeutic doses of radiation rather than diagnostic. What does our eminent academic draw from this horrible incident? That greater regulation should be in place to improve the training of technologists, to standardize radiology protocols and techniques, to monitor delivered doses and compare them with benchmarks, and finally to reduce the number of CT scans used by reducing profitability of imaging[5], all of which may be true. But I was flabbergasted and infuriated: the issue to me was that no imaging should have been done on this patient. A thirty-second examination would have sufficed to make the diagnosis: ask the patient to furrow their forehead. If they could not, then we have a peripheral seventh nerve palsy, i.e., a Bell's palsy. Send the patient home with some steroids and tell them to follow-up with their primary care physician. This example is not a failure of regulation but rather that of an inability to connect physical findings with history to make a diagnosis. How very sad for our profession.

Back to our Professor of "Value-Based Care Research" who informs us that "we… need to reeducate our patients"[6] not to expect a physical examination. I believe that shows a profound lack of understanding of human nature. As one of my professors in college used to say human beings are "unrational"[7], not irrational or crazy, but unrational. Shaking hands, breaking bread, embracing, talking face-to-face, making eye contact, and laying hands on in the act of examining make a profound human connection, attaching the patient to the doctor and the doctor to the patient. In the Academy of Medicine board room there is a copy of the famous picture "The Doctor", which shows a physician seated in the wee hours of the morning looking at very young and ill girl. The key to this picture is that the the child died and the father nevertheless felt compelled to produce the painting. The patient had a "bad outcome" and no "value" was added to the patient's care by the physician sitting with a dying child all night. The father, however, would beg to differ. The message the father received ,which we as a profession are failing to send, to quote Dr. Abraham Vergese is that  "(we) will be with you till the end"[8].

Now I am not being completely fair to the esteemed Dr. Rothberg. He specifically only attacks routine yearly physical examination but the impression he leaves is that all physical examination examination is of doubtful utility. Clearly I beg to differ. In Winston Churchill's description of the Munich crisis[9] he describes two paths that could have been taken each of which had cogent arguments (of course, Churchill being Churchill, he felt his were stronger). Nevertheless, he describes a guide to making difficult decisions when good arguments are placed on either side. The guide has the underlying assumption that human wisdom is not all that great that many things in life are too complex and perhaps unrational to measure. The guide is honor: a very old-fashioned and, to some, anachronistic idea. I ask you where does the honor of our profession lie?

[1] JAMA, June 4, 2014,;311;21;2175
[2] Sir Arthur Conan Doyle's professor on whom he modeled Sherlock Holmes.
[3] Of course, what is obvious to one may be subtle to another. When I was a medical student, I had a professor – actually, I had more than one professor – of cardiology, Leon Resnekov, who upon completion of a cardiac examination would make a "Resnigram" documenting the cardiac examination with exquisite precision, including the splits between heart sounds down to hundredths of a second. The new Fellows assumed he was exaggerating his skill and would order an echocardiogram. They discovered, much to their dismay, Dr. Resnekov was as accurate as the machine of 30 years ago. Today, I doubt this level of expertise is necessary.
[4] NEJM 2010; 363; 1 – 4
[5] Ibid.
[6] JAMA; 311; 21; 2176
[7] John Danforth, personal conversation
[8] Abraham Vergese, TED Talk, July 2011
[9] Winston Churchill, The Gathering Storm, p, 319 – 321. He also presents similar but slightly different arguments twice in Marlborough: His Life and Times but as my edition is six volumes and roughly 2700 pages I cannot easily find the exact references.


  1. i enjoyed reading this post and other posts on this blog. Thank you.

  2. Thak you. The best ones, I think, are the early ones written by my wife.