One Doctor's Mission To Revive The Humble Physical
JENNIFER LUDDEN, Host:
This is TALK OF THE NATION. I'm Jennifer Ludden.
A recent story in The New York Times about the dying art of the medical physical exam caught our eye. The physical used to be the way doctors diagnosed aches and illnesses - a poke here, a prod there, looking, listening. Much of what ails us now is diagnosed by expensive machines and technology.
But one doctor is on a quest to bring back the physical exam. He's Abraham Verghese, professor for the theory and Practice of Medicine at Stanford University and author of the novel "Cutting For Stone." He joins us in a moment.
We want to hear from the doctors in our audience once again. Do you use a physical exam for diagnosis? If not, why not? And patients, when was the last time your doctor did a physical exam? Do you miss them? 800- 989-8255 is our number. Email us at firstname.lastname@example.org. And join the conversation at our website. Go to npr.org and click on TALK OF THE NATION.
Dr. Abraham Verghese joins us now from a studio at Stanford University. Welcome to TALK OF THE NATION.
ABRAHAM VERGHESE: Thank you for having me.
LUDDEN: Why is the physical exam so important?
VERGHESE: Well, I want to begin by saying that I'm not a luddite, and it's not that I don't like technology, but there really are so many things that are quite self-evident on the body if you only look and know how to examine a patient. And it seems to me a crying shame that we often subject people to expensive imaging when the body was telling us all along what was going on.
And I think also, if you do a good physical, I find time and time again, I'm able to ask a better question of the CAT scan or the MRI, rather than what in the world is going on. I know the liver's enlarged, and I'm curious about the right lobe because I think there's something there. You know, it's a higher order of magnitude. And I think that's what patients deserve from us.
LUDDEN: You write that it also is a question of building trust?
VERGHESE: Well, you know, it's a strange thing. In the 20, 30 years that I've been practicing, I've become more convinced that a thorough physical in the context of a new patient or a patient at the hospital is a very symbolic act. I mean, if you think about it, here's someone telling you their deepest, darkest secrets and then disrobing and allowing touch - which, in any other context, would be assault. And I think that our skills have to be worthy of this very sacred ritual, and patients pick up at once when you're sloppy or you put your stethoscope on their nightgown.
In fact, I spent time sort of collecting phrases people use to complain about us, and it's striking how often they say things like he or she never laid a hand on me.
VERGHESE: He or she never touched me. So even we - even if we, as physicians, have maybe, you know, think it's not that important - I can get the data this way or that way - clearly, to the patient, it's central. And I come to think of it as a way of taking their story and giving it body, in a sense. You're acknowledging and validating this complaint of theirs in the process of the examination.
LUDDEN: So how has it come about that, apparently, many doctors don't do the physicals anymore?
VERGHESE: Well, I think what's happened is the abundance of imaging. One of my colleagues here at Stanford, Alan Garber, used the phrase, you know, American health care is like a menu without prices - you know, filet mignon every night if you want it.
(SOUNDBITE OF LAUGHTER)
VERGHESE: And I don't think I or my residents really pause to think about how much does this test cost or that test cost. Somebody's paying for it. And I think that's brought about a sense of sloppiness about, you know, the cost of things, and more than that, a distrust of our own abilities. So I only (unintelligible) that in a hospital in America, if you show up missing a finger, no one will believe you till they get a CAT scan, MRI and orthopedic consult.
(SOUNDBITE OF LAUGHTER)
VERGHESE: You know, it's almost as though the skills of 150 years have atrophied when, in fact, they should be a hundredfold better because we now have ways of validating - well, this test is pretty useless and this physical diagnosis maneuver is actually pretty good.
LUDDEN: Well - and how accurate can a physical be? I mean, you know, I can understand saying, well - okay, maybe not if someone is missing fingers. But if you're looking at something internally and - why not go to the, you know, X-ray machine or the cam? How accurate is the physical for diagnosing things?
VERGHESE: I mean, I don't think one should make any pretentions about it being, you know, highly accurate. But the point is, you might not order the right test if you don't stumble onto something on the physical or in the history for that matter that might lead you to the correct thing.
So I'm concerned, in America, that we have become obsessed about a certain kind of medical error, you know, the wrong limb getting operated on, the wrong medication. But there's a whole other kind of error that we're not beginning to compute or to capture and that is someone has a story to tell you that would immediately point to the diagnosis. But in your haste to get on with things, you miss it. Or more importantly, someone has a finding on their body, for example, tenderness when you palpate the abdomen...
VERGHESE: ...that shouldn't be there that should lead to the order of the correct image. I don't think the solution is, you know, run everybody through a giant machine no matter what their complaint is. But the physical often leads you to things - you know, to tie in with your previous session, you might find a breast lump in someone who has come to you for something else. And that might be the moment of discovery that could lead you down the right path.
And my nightmare is that someone is going to come through my office with a diagnosable, treatable condition that I missed from sloppy technique.
LUDDEN: Hmm. Let's take a call from a listener. Eileen(ph) is in Tampa, Florida. Hi, there.
EILEEN: Hello, there. Thank you for taking my call. I am not in the medical practice other than being a patient and knowing socially multiple professionals. And the issues that I hear are threefold. I hear extreme frustration and almost depression from physicians because they are not allowed the time anymore to do the physical and take the history. And when they do, they're working - if they're working with a hospital or with the - a contractor, a corporation instead of a private practice, they are using more than the time with the patient.
But on the other hand, I hear great joy from some of these doctors because they'll get patients in that have been misdiagnosed, mistreated, and they'll ask a simple question like, have you had surgery before? And the patient will say, no. But when they do the physical, they'll go, oh, what's that scar? And he's, oh, yeah. Twenty years ago, they took out a - I just forgot about that.
EILEEN: Or they will - in the physical exam, I know one time he - I'm thinking of somebody - that the guy had had celiac disease and he had been treating for psoriasis. And for two years, he has been miserable.
By taking the time to take a detailed history and do a real - what I call an old-fashioned physical, these patients are getting better care. They're getting better outcomes. They're saving their provider money, yet the doctor is constantly harassed for using more than his 20 minutes.
LUDDEN: Dr. Verghese, is this is a matter of too little?
VERGHESE: I think that's a very insightful observation, and this is a major part of the problem. So I have colleagues who tell me that they're going to concierge medicine primarily because the other kind of primary care practice, they have to see 20 to 30 people to pay the overhead. And no one wants to be driven like that. It shortchanges everybody. So I think time is clearly an issue.
And even more importantly, I think we're reimbursing in health care for the wrong things. We pay for people to do things to people and not to do things for people. I mean, you look around you see freestanding short- stay surgery centers, short-stay labor rooms, you know, cancer centers. When is the last time you saw a freestanding geriatric center?
LUDDEN: Hmm, right.
VERGHESE: And the other - if I take my father or mother to see a physician, they need a good 45 minutes just to voice all their concerns and be seen. And frankly, there is no money in that for most people. And so it's a very difficult proposition ahead for us if we don't perform health care.
LUDDEN: All right. Eileen, thanks for that phone call. Let's go to Boston now, Julie(ph) in Boston, Massachusetts. Go right ahead.
JULIE: Hi. This is a great conversation. I'm a nurse at Dana- Farber and at the VA, and so I have several comments. First, they keep saying physicians and MDs. And nurse practitioners are actually becoming an increasingly important role, particularly in primary care, doing physical exams, and actually have more time with the patients. The other thing I want to say, which I think nursing is still that, is teaching the patient about their own bodies so that they can monitor themselves. And I think that's as important in the physical exam as anything.
LUDDEN: All right. Julie, thanks so much for calling. We have another one quick here. Reina(ph) in Boca Raton, Florida. Go right ahead.
REINA: Thank you so much for receiving my phone call. I'm so delighted to have this conversation on the radio. I'm an acupuncture physician in the state of Florida. We're primary care physicians. We were taught to do physical examinations, and it's actually one of the most important things that we can contribute to our patients. Through doing the physical examination, we can see what they are actually hiding, what they may have forgotten. Just like the other caller said, oh, the surgery that they forgot 20 years ago. We can garner from them in their body and also in what they're telling us, like, what exactly is going on with the person as a whole.
Oriental medicine is definitely concerned with the amount of people that are being run through the Western medicine model. And they're coming to us in later stages of illness and seeking help.
So I'm so grateful that you're having this conversation. I just want (technical difficulty) that it's very important to be touched by your physician, to have physical contact with them alters the dynamic between a patient and a physician. And I just wanted to thank you again for having this discussion. And I hope that everyone out there listens to the fact that they need to be more close to their physician.
LUDDEN: All right. Thank you, Reina. And Dr. Verghese, we've got an email here as well from Casey(ph) in Wake Forest who says he's an emergency physician, relies on a physical exam everyday, and says, incidentally, the history you take from the patient is usually four or five times more important than the exam and tests all put together.
VERGHESE: Yeah, I wouldn't disagree with any of those things. And I actually - good points your previous listener made. You know, I think that one of the things that we're learning is that the placebo effect is much more complex than, you know, a sugar pill instead of a real medication. The placebo effect has to do with the context of the delivery of health care, who delivers it in what voice, wearing what coat.
And we're finding that placebo can produce profound neurobiological effects. You give a Parkinson's patient a placebo and their dopamine levels go up. You can block pain with a placebo that you tell the patient is a morphine antagonist. You know, really profound things happen with placebo. But I guess what we're also learning is that the ritual of examining the patient has its own positive effect.
And I think that part of the reason that, you know, not to take anything away from their wonderful skills, but the additional part of the reason why acupuncturists and so many other alternative medicine practitioners are so successful is because, as the commenter said, they spend time, and they put their hands on, and there's a ritual. And I think that that activates a very important placebo effect. And I use that term in a very positive way.
LUDDEN: You're listening to TALK OF THE NATION from NPR News. Margreta(ph) - did I say that right or is it Margarita(ph)?
MARGRETA: That's correct.
LUDDEN: Margreta on the line in Moscow, Idaho.
MARGRETA: Yes. I'm a veterinarian and I've been one for 45 years. And of course I do physicals everyday and know how they important are with my patients.
LUDDEN: You can't really ask them how they feel, can you?
(SOUNDBITE OF LAUGHTER)
MARGRETA: And I had a wonderful physician who is now retired and he did a very efficient, extremely thorough physical when I went in to see him, also talked to me. And it didn't take any more time than anything else, and I felt very, very comfortable when we were done.
Then I - he retired so I - it took me a long time to find a recommendation for a physician. I went to this person. She spent 20 minutes entering into the computer what I had on my - in my hands, all my history and my medicine and so forth, and then never laid a hand on me. I asked the three questions about things that I needed answers on. None of them was given an answer that was acceptable.
LUDDEN: Lady, if you think I don't know the difference between my anus and my vulva, you know, I have three children - whatever. And - but I didn't say that because I didn't think of it until later. But I finally keep - and I told her I have asthma all my life and she finally listened to my chest and said, yes, you have asthma. I was like, okay. And that was it. And I have never gone back. I was so angry and so disappointed, and I was charged an extended exam for that and I got nowhere.
LUDDEN: All right. Well, thanks for calling us.
MARGRETA: I was really sad, and I feel bad for visiting them. But I'm a veterinarian, I think we can, you know, we have more opportunity to be a little more creative. And sometimes - the guys do a great job, but we can be creative and try to get to the bottom of things without charging an arm and a leg. And I understand how difficult it is in medicine.
LUDDEN: Margreta, thank you so much. Dr. Verghese, you say that some doctors just kind of go through the motions. They know a patient wants a physical exam, so they'll just kind of do it as a...
VERGHESE: Well, I think the real feeling is - our feeling as teachers, because I think what has happened over the years is that we have held people to very high standards in terms of their cognitive knowledge base, how much they need to know. But, for example, in my specialty, internal medicine, when I become board certified in internal medicine, it involves a multiple choice test. No one actually sits downs with me and sees if I know how to feel a spleen or elicit a reflex with a knee hammer, you know? And so I think there have been too many gimmes in this aspect of the physical.
So I talk with young physicians. It's not that they don't value the exam. They will tell you candidly that they don't feel confident in it. And that is sort of the thrust behind our program here, the Stanford 25, where we're trying to really make sure that our interns, our residents are second to none at the bedside, and that there will be no gimmes in their skills. What they say they did, they did.
Now, I just wrote an editorial, which I titled - with my colleague, John Kugler - "The Bedside Ritual and Other Forms of Fiction." Because if you look at the electronic medical record these days, it's a form of fiction. They have ticked off boxes for reflexes, cranial nerves intact, chest clear, this and that. Honestly, Jennifer, we don't know if they've really done this stuff. And the record looks just magnificent and perfect, but if one ever did an audit one on one and mashed up what was actually done - recorded by a video camera with what's recorded, I think it really is a form of fiction. And we at Stanford really want to reverse that with our trainees.
LUDDEN: Now, are you a lone voice on this? You talked about how when you were studying medicine, you know, you had to study the cadaver for a year. And American medical students don't get anywhere near that. We're just about out of time, but do you have any sense that you're not the only out there trying to revive this?
VERGHESE: Oh, I think I'm far from the only one. I think there's a large sentiment that feels that, you know, that this is so important. And what I think is terribly revealing to me is this article in The New York Times about the bedside exam, overwhelming emails from patients who get it. They say, this is absolutely what we need. I think we, as physicians, have been loathe to really recognize how important that is. And you can't talk about patient satisfaction if to you that means ordering tests and ticking off boxes. It does involve real skill at the bedside.
LUDDEN: Dr. Abraham Verghese is professor for the theory and practice of medicine at Stanford University and joined us from studios there. He's also the author of the novel "Cutting for Stone." Thank you so much for your time.
VERGHESE: Thank you for having me.
LUDDEN: I'm Jennifer Ludden. This is TALK OF THE NATION, from NPR News.
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