Another very interesting thread in my opinion about a doctor's age versus the completeness of their physical exam. I feel that I need to clarify what a physical exam is . A physical examination is the process of evaluating objective anatomic findings through the use of observation, palpation, percussion, and auscultation. The information obtained must be thoughtfully integrated with the patient's history and pathophysiology.
I think what Jay11ish refereed to in this thread is a periodic health examination. How often this is done depends on the patient's age, sex, and risk factors for disease. It provides an opportunity for the healthcare professional to obtain baseline information about the patient for future use, and to establish a relationship before problems happen. It provides an opportunity to answer questions and teach good health practices. Detecting a problem in its early stages can have good long-term results.
A complete physical examination usually starts at the head and proceeds all the way to the toes and should takes about 30 minutes. First, the examiner will observe the patient's appearance, general health, and behavior, along with measuring height and weight. The vital signs—including pulse, breathing rate, body temperature, and blood pressure—are recorded.
With the patient sitting up, the following systems are reviewed:
-- Skin: The exposed areas of the skin are observed; the size and shape of any lesions are noted.
-- Head: The hair, scalp, skull, and face are examined.
-- Eyes: The external structures are observed. The internal structures can be observed using an ophthalmoscope (a lighted instrument) in a darkened room.
-- Ears: The external structures are inspected. A lighted instrument called an otoscope may be used to inspect internal structures.
-- Nose and sinuses: The external nose is examined. The nasal mucosa and internal structures can be observed with the use of a penlight and a nasal speculum.
-- Mouth and pharynx: The lips, gums, teeth, roof of the mouth, tongue, and pharynx are inspected.
-- Neck: The lymph nodes on both sides of the neck and the thyroid gland are palpated (examined by feeling with the fingers).
-- Back: The spine and muscles of the back are palpated and checked for tenderness. The upper back, where the lungs are located, is palpated on the right and left sides and a stethoscope is used to listen for breath sounds.
-- Breasts and armpits: A woman's breasts are inspected with the arms relaxed and then raised. In both men and women, the lymph nodes in the armpits are felt with the examiner's hands. While the patient is still sitting, movement of the joints in the hands, arms, shoulders, neck, and jaw can be checked.
Then while the patient is lying down on the examining table, the examination includes:
-- Breast: The breasts are palpated and inspected for lumps.
-- Front of chest and lungs: The area is inspected with the fingers, using palpation and percussion. A stethoscope is used to listen to the internal breath sounds.
The head should be slightly raised for:
-- Heart: A stethoscope is used to listen to the heart's rate and rhythm. The blood vessels in the neck are observed and palpated.
The patient should lie flat for:
-- Abdomen: Light and deep palpation is used on the abdomen to feel the outlines of internal organs including the liver, spleen, kidneys, and aorta, a large blood vessel.
-- Rectum and anus: With the patient lying on the left side, the outside areas are observed. An internal digital examination (using a finger), is usually done if the patient is over 40 years old. In men, the prostate gland is also palpated.
-- Reproductive organs: The external sex organs are inspected and the area is examined for hernias. In men, the scrotum is palpated. In women, a pelvic examination is done using a speculum and a Papamnicolaou test (Pap test) may be taken.
-- Legs: With the patient lying flat, the legs are inspected for swelling, and pulses in the knee, thigh, and foot area are found. The groin area is palpated for the presence of lymph nodes. The joints and muscles are observed.
-- Musculoskeletel system: With the patient standing, the straightness of the spine and the alignment of the legs and feet is noted.
-- Blood vessels: The presence of any abnormally enlarged veins (varicose), usually in the legs, is noted.
In addition to evaluating the patient's alertness and mental ability during the initial conversation, additional inspection of the nervous system may be indicated:
-- Neurologic screen: The patient's ability to take a few steps, hop, and do deep knee bends is observed. The strength of the hand grip is felt. With the patient sitting down, the reflexes in the knees and feet can be tested with a small hammer. The sense of touch in the hands and feet can be evaluated by testing reaction to pain and vibration.
-- Sometimes additional time is spent examining the 12 nerves in the head (cranial) that are connected directly to the brain. They control the sense of smell, strength of muscles in the head, reflexes in the eye, facial movements, gag reflex, and muscles in the jaw. General muscle tone and coordination, and the reaction of the abdominal area to stimulants like pain, temperature, and touch would also be evaluated.
It should be noted that with certain aspects like the Reproductive exams your GP or Family doctor may forgo in favour of a gynecologist or urologist.
I personally think that there are a number of factors that influences how thorough or complete an exam you receive. Age I feel is one such relevant factor as being competent occurs from practice which you gain from experience which takes time. As you gain experience over time you become an Expert which implies extraordinary proficiency and often connotes knowledge as well as technical skill, all of which aids how thorough a physical you get.
Another factor that needs consideration is the Doctors own level of dedication when comes to actually performing the exam, as with all professions some are more dedicated than others .
JimmyJohnson makes a couple of excellent points:
The schools where they were trained and the policies of their current practice probably have more impact than their age.
Having worked with doctors from all over the world I can attest to their various levels of thoroughness which performing a physical exam. This to a large extent depends on their training in medical school and their post qualification training .
This may be more of an issue in the US than the UK where the cost of the examination will depend on the charge for the professional's time and any tests that are done coupled with the individuals health insurance and what they allow.
Both Andie and Docinny45 provides another factor:
Everyone has their own opinion of what constitutes completeness and thoroughness for any exam with any medical provider during a scheduled appointment, urgent appointment, emergency visit and referred consultation etc. What I feel is most important is that what needs to be taken care of in the appointment is properly taken care of, questions, concerns, issues addressed and nobody has their time wasted or taken advantage of on purpose. This includes the patient and all medical staff.
Unfortunately, people equate thoroughness with "doing doctor stuff". Rarely does that "doctor stuff" give me the key to what's going on with the patient. They don't equate knowing what to ask, and integrating the patient's answers and adding the next appropriate question to finally reach a diagnosis as being thorough.
Individuals will have their own opinion about what constitutes a complete and thorough physical, so this is very subjective and open to a wide variation in its interpretation. So what is perceived by someone may not be for others .
Finally Srg Rik makes an excellent point:
I believe that two of the most important (but often overlooked) skills for a physician are to be a good listener and a good questioner. May people understate their symptoms on a written history, with forms being so prevalent now, or even when speaking with their doctor. If a good exam is predicated, in part, on the history, then the history is only as good as the physicians communication skills allows it to be.
We can all relate that some doctors do have a well developed sense of the "god complex" which can often exclude effective interpersonal and communication skills. That unshakable belief characterized by consistently inflated feelings of personal ability, privilege, or infallibility so it would not come as a surprised if they are not as thorough as they should be.