Interesting article on what constitutes a complete physical exam.

Http://pediatric-house-calls.djmed.net/without-good-physical-exam-patients-loose/

Is this article unduly harsh, right on the money, or not tough enough on the current state of the physical exam?

Very accurate. Even the physical exam techniques that I teach aren't really complete, mostly due to the piecemeal education (this week - abdomen. Next week - cardiac and pulmonary) and the adherence to the manufactured issue of patient modesty.

In real life, other than at the dermatologist, I can't remember when I was asked to 'strip to your skivvys.' EVERYTHING is done through clothes or with minimal exposure. My melanoma wasn't found by a doctor - how can they through clothes? I found it and reported my suspicion. Unacceptable.

I think the author of this article has an ax to grind. I know of few physicians including myself who don't do a good history and physical. It's simply not necessary to have the patient undressed all at once. The patient can be placed in a gown and sequenctially undressed so that the entire body can be examined. I also believe in a history driven physical exam. In my forty plus years of practice I've found it rare to pick up a physical finding which has not been alluded to in a comprehensive history. Obviously there are certain exceptions such as dermatology exams. He also needs to have his article proof read as it's losing not loosing.

My real life experience in two different states (except dermatologists) doesn't even include a gown. I'm commonly fully clothed. At the urologist, just drop the pants for about 1 minute. At the PCP, ascultation thru clothing. At the cardiologist, shirt off only for the EKG.

I'm with liquidsky on this, he seems to have an axe to grind.

He also seems unaware of the difference between 'lose' and 'loose'.

I have to disagree with the author. It's nice to site scary examples of what happens when you don't physically examine your patient, but there is a lot more to medicine than the exam part.

The best clinical professor I had in med school drummed into us that it's all in the history. He's more right than the author of that article will ever be. Sure, you can't just ask someone with an enlarged spleen if they feel anything in their abdomen. THAT'S NOT A HISTORY. Fatigue? Fever? Sore throat? Clinical thinking, the formation of a differential diagnosis. Yes, examine the abdomen looking for an enlarged spleen but WHY IS IT ENLARGED? Rarely is "big spleen" the diagnosis. Mononucleosis? THAT'S a diagnosis. Lymphoma? THAT'S a diagnosis. How do you tell them apart? By the HISTORY. Then when you find the enlarged spleen and lymph nodes, you gather more data to support or not support the preliminary diagnosis. You form a differential which allows you to weigh the possibilities until you reach a diagnosis and formulate a treatment plan.

I have a book "Cope's diagnosis of the acute abdomen". Great book. Lots of good exam techniques. Much of it is obsolete because I can get a much better idea of what's going on with a CT scan..

The "review of systems" performed by most doctors is a farce. A lengthy check list of symptoms rattled off, most of which contribute nothing actually reaching a diagnosis, is the creation of bureaucrats. Most doctors I know dictate "eleven systems were reviewed and were negative except as noted above in the HISTORY"

He's having trouble finding a doctor that meets his standards.. I'm very glad he's not my patient.

Oh, and Jds4med, most of my patients are fully clothed. Not my preference. In our area people seriously do not want to disrobe unless they have to. I use an electronic stethoscope with digital noise canceling so I can hear what I need to hear through their clothing. If they have too many layers, I'll have then remove some. I would much prefer a patient in a gown.

Doc

IMHO it is a two sided blade I went to one doctor and was overmedicated for one condition that put me in the hospital while the problem that I was there for was Ignored. I think That it works both ways, if you are paying for a service and are not getting it then say something. But if you do not have a problem then there probably is not one there However it is a good thing for any doctor to have a nice baseline oof a patient health whatever happened to the yearly complete physical? seems to me they used to take more than five minutes for my doctor to do a full exam and now they seem to have the amazing ability to diagnose by jost looking at you and giving you a few pills pain is stil there but you do not care lol. Just some rambling there are some great docs out there funny thing is my PCP these days is A NP have not seen an actual primary doc in years lol apparently Insurance companies decided that it just makes more sense. Another subject for another time! lol.

Sub-

It is said that men don't like to see a doctor. Or ask for directions if lost. So should we ignore their not liking in the case of healthcare? And if they don't like to get undressed, but doctors feel that an undressed patient exposes the body, and possible unmentioned or unnoticed issues, should we let them stay dressed and work around it? Having seen the divide in NYC between how NYU internal medicine doctors did exams versus some other hospital systems, I stayed with the former, allowing others who didn't like things to choose the latter. Those of us old enough to recall how physical exams were done when doctors made decisions will recall being undressed.

Hi,

I hear you all, what troubles me is that physicians clearly do not have the time to deal with patients, more pressure is put on them to see more, I have heard this from my GP, therefore even if they wanted to do full comprehensive examinations the time does not cater to it. I do agree family history and your personal history plays a lot into it, however I feel this is a bi product of the awful situation medical care has deteriorated to in the US. Its the luck of the drawer. I do not see it getting any better with a new administration. I am fortunate I have a GP who listens to me, she is patient calm and asks the questions based on my complaint, which isn't often.