Disappearing art of the physical exam

This is an interesting podcast on the watering down of physical exams in recent times due to technology

http://www.npr.org/templates/story/story.php?storyId=129931999

IBM used to give all new hires quite an extensive pre-employment physical before ADA was enacted in the early 1990s.

This is an interesting podcast on the watering down of physical exams in recent times due to technology

http://www.npr.org/templates/story/story.php?storyId=129931999

Interesting indeed and probably very appropriate.

I've noticed my exams getting less and less thorough over time, which seems like a related issue. Maybe it's cuz I'm still young and healthy...

I have an appt on Friday with my primary care physician for a physical exam, but I'm not expecting anything beyond blood work, heart and lungs and ear, nose & throat. He'll have me get undressed to my underwear and put on a gown, but it makes no sense as to why. He doesn't do a genital exam anymore nor a prostate exam. Good thing I see my urologist once a year for that part, otherwise it wouldn't happen. Pretty pathetic. I'm very close to switching to a internal medicine specialist, who would be far more thorough.

A very interesting article, but I'm not really surprised by it. I have seen the change in physical exams over the years, as a child our GP was old schooled so you were examined at each consultation. With the GP's nowadays its always a very rush job, sometimes no physical exam at all, just blood work, scans and other technological investigations. Its really a shame that a thorough physical exam is being watering down in favor of technology as doctors try to see more and more patients in a shorter time frame.

But what is truly annoying and disturbing is that this greater reliance on technology is actually increasing the cost of healthcare year on year. A good and thorough physical exam would not only reduce the cost of healthcare but also most probably detect abnormalities and possible instigate treatment at an earlier stage as highlighted in the article.

Don't get me wrong technology has its place in modern day healthcare, I work in ITU ( ICU) and without technology we would not be able to perform our jobs effectively ( ventilators, cardiac monitors, infusion pumps, portable ultrasounds to aid line placements, CT scans, MRI, Xrays etc ).

I too have been noticing a decline in the thoroughness of my physical exams. When I was at my pediatrician my exams were pretty thorough. Just about everything was examined. When I switched to a family doctor my exams were very basic. Nothing below the waist was examined even though I had to strip to my underwear. This concerned me so I transferred to another family doctor and since my exams have been a little more thorough but not as thorough as my pediatric exams. She doesn't do reflexes or a genital exam, but does just about everything else.

Family practitioners are maxed out in the current setting no doubt about it. And they're trying to see as many patients as possible in a given day. They are not spending the amount of time with each patient as they should. Internal medicine physicians I've heard are much better.

Based on my own experience, I too believe that internists are generally more thorough than family practice docs. I've had both in the past and it just seems that way to me. Of course it also depends greatly on the individual doctor as well as the type of practice that they're in.

I feel a complete physical exam is not what it used to be. A physical exam should be a half hour examination not a 2 minute in and out

The problem about an extended physical exam is that there is simply not time to perform this. Besides everything that needs to be examined can easily be done in ten minutes.

The problem about an extended physical exam is that there is simply not time to perform this. Besides everything that needs to be examined can easily be done in ten minutes.

I'm also pretty certain that a doctor will also rely on a patient's concerns. If for instance they have experienced a problem of one kind or another, it behooves a patient to tell the doctor so that he can check that specifically.

For instance a problem with the ears or nose. In all my years I don't think a doctor has ever taken a look into my nose. Just last week for instance I found out that I have a small abnormality with one or another bone that divides the nostrils. If I hadn't had another concern in that part of the body I never would have known because it's not a main concern during examinations.

The problem about an extended physical exam is that there is simply not time to perform this. Besides everything that needs to be examined can easily be done in ten minutes.

It's not that there's not time, it's that medicine in its current corporate state doesn't allow the time.

I agree that if I come to the doctor for a complaint, there should be a focused exam, but periodically there should be a complete exam. There are places that specialize in the "Executive Physical." It costs money, but you're buying the doctor's time,the way it used to be before managed care.

The problem about an extended physical exam is that there is simply not time to perform this. Besides everything that needs to be examined can easily be done in ten minutes.

I agree that screening physicals can be done in ten minutes on younger patients. That is the duration of exams I have had all my life and I am now in my early forties. This assumes the subject of the exam has no significant physical complaints. I had that duration of exam for sports as a kid and teen, college and grad school entrance, pre-employment, and personal life and disability insurance. All these exams include vitals, eyes, throat and neck, axillae, heart and lungs, brief neurological screening, abdomen, genitals and hernia, and sometimes rectal. The exam is usually accompanied by basic blood tests and urinalysis and drug screen. All this is easily done in ten minutes and provides a basic health screening.

This is a little late to comment on your post Jds but I can do a complete exam in fifteen minutes. To prolong it is just to gild the lily.

A lot of what constitutes an appropriate physical exam depends on the setting. If the patient walks into the exam room and has no complaints, 15 minutes is more than adequate. For example, if he/she walks in and answers all questions fluently and appropriately, you can pretty much omit a neurological component. If there is a history of shortness of breath or edema, the cardiovascular exam is way different than if these signs/symptoms is absent. So...it all depends.

I agree that a full screening can be completed in under 10 minutes. An exam I had 3 years ago by an internist was actually the least complete exam I had ever had. I was fully dressed throughout except for a quick lift of the shirt and drop of the pants.

I normally take about 45 minutes to complete a full examination...

Yes but yours are for pleasure. Mine are strictly biz.

Very rarely have I missed anything. The reason is that the preceding history makes the exam focused. I've also gone back and repeated the exam when I'm unable to find an explanation for the history. Later. lab findings corroborate the combined history and physical exam.

These days it seems it is all about Blood Work. They can pretty much tell anything from Blood Work. The actual Physical Exam is an aside to the Blood Work. If you have four to six tubes of blood drawn you can bet they will find just about anything.

That's totally ridiculous. Let me tell you lab work can save your ass. And mine. The most important thing in making a diagnosis is the history. And asking the right questions is how you finesse it. The physical exam is just secondary to the history. As I've said previously, if you don't know what the diagnosis is after you've taken a history you're in a world of trouble.

My primary care doctor schedules a double time slot for complete physicals as opposed to a quarterly check up on my diabetes. The time slot for that physical is booked six months out.

An exam on a diabetic patient includes components you would never need to do in a routine exam with no other historical info to suggest it. As Liquidsky has said (preceeded by my Physical Diagnosis prof) history is 80% of the way to the diagnosis. Exam is 15%. Other testing is generally confirmatory tho in diagnosing some conditions, especially early, screening lab does play a big role. My gripe is letting lab and imaging substitute for diligence with history and physical exam. And my experience teaching medical students, as recently as a month ago, suggests that process is well under way.

I agree - my doctor spends 90 seconds max examining me. He ausculated my heart through a pretty thick shirt last time!!

This is why I've often said that - acknowledging how common it is for medical fetish to arise from or be fueled by exams in our youth - I'm glad I grew up in the 70s and 80s when a physical exam was a real process, different from a quick visit to the clinic.

I had my annual 'wellness exam' yesterday. The only human touch was vitals with the nurse and handshake with the doctor. Zero exam extensive discussion of prescriptions.

I had my annual 'wellness exam' yesterday. The only human touch was vitals with the nurse and handshake with the doctor. Zero exam extensive discussion of prescriptions.

My last physical exam experience within the last 6 months parallels JDS's. Sigh... yet another avenue for caring, intimate, pseudo-erotic human touch gone. "Progress" is wonderful, but stuff like this makes me hate it sometimes.

I think that it depends on the type of doctor that the patient chooses for physical exams. An internist is going to be more thorough than a family or general practice doctor. I agree that the history part takes more time than the physical exam part but there are only so many ways for a doctor to do a physical and even the most thorough exam doesn't take a lot of time. I have never timed the physical exam part but I doubt that it takes more than 10 minute max and that includes checking everything. I have had very similar exams over the last 30 years and all with internists. I can't say that physicals have become less thorough.

(I have posted these thoughts elsewhere, so for those who haven't seen them.)

My first real doctor in the 1960's (tying various posts here) was internal medicine, replacing pediatrics. His exams were slow and steady. He did everything, including height and weight. He started at the top, and made his way down. He included racing heart after brief jumping jacks. I was in briefs, then naked. He made hospital rounds in the morning, then made his way through patients at a medical practice.

As a rule from that time, NYU affiliated, trained internal medicine doctors were the most detailed in their exams. Internists in NYC seemed to be more detailed. Over time, starting in the 1990's, I noticed gown creep, and, consequently exams which almost seemed to examine only what wasn't covered by one. Gay doctors never hesitated about full body inspections.

Finally, I, too, would have given up on resetting the clock. Gowns gave way to fully dressed. Invasive gave way to let's not bother the patient. Let's talk and type on our laptop. Until my Canadian family doctor, who has brought things all the way back, to a slow and steady exam, with me in briefs, then naked, complete skin check, and everything else. The only thing that he doesn't do is height, weight, vital signs, and lab work.