The Fading Art Of The Physical Exam Doctors used to make their diagnoses based partly on the patient's history and a physical exam, but with the increasing use of high-tech medical tests, some doctors worry that the art of the medical exam is being lost.

The Fading Art Of The Physical Exam

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It's MORNING EDITION, from NPR News. I'm Steve Inskeep.


And I'm Linda Wertheimer.

Today in Your Health, we'll hear what a human touch does to the brain.

But first, NPR's Richard Knox looks at what a doctor's touch can do for your health. It's the traditional, hands-on physical exam, and it's disappearing as a way for doctors to diagnose what's wrong.

RICHARD KNOX: If you have a symptom of possible heart disease, you're likely to get a $500 test called an echocardiogram.

Dr. JASON WASFY (Massachusetts General Hospital): Turn a little bit towards me.

KNOX: In Boston, Dr. Jason Wasfy sits at a machine that displays a patient's beating heart.

Dr. WASFY: All right. So now we're going to look at one of the valves in your heart, OK? We're looking at the flow through it.

(Soundbite of echocardiogram machine)

KNOX: More and more, doctors rely on echocardiograms and other fancy technology.

Dr. WASFY: We're now often doing expensive tests where, in the past, a physical exam would have given the same information.

KNOX: That information can be critical. Roman DeSanctis of Massachusetts General Hospital is one of those doctors who's famous for his diagnostic skills. A few weeks ago, he saw a patient whose lungs were filling up with fluid. The man had lung cancer, but his primary care doctor had totally missed it.

Dr. ROMAN DESANCTIS (Massachusetts General Hospital): And I said, Did Dr. So-and-so mention anything about this when he saw you? And he said, well, he took my blood pressure, but he didn't really examine me. This is not an isolated case.

KNOX: Many doctors have abandoned the physical exam. But some are bucking the trend.

Dr. NESLI BASGOZ (Massachusetts General Hospital): I am going to just take a feel and listen of your heart, OK?


KNOX: Dr. Nesli Basgoz of Mass General is doing an exam on a patient called Barry Archangeli.

Dr. BASGOZ: And I hear the normal heart sound, but then I hear kind of a blowing murmur.


Dr. BASGOZ: And it's loud, and it's long.

KNOX: To the doctor's trained ears, this patient's heart murmur is immediately obvious.

Dr. BASGOZ: Do you hear it?

KNOX: She offers the stethoscope to Archangeli so he can listen.

Dr. BASGOZ: OK. Try that. Whoo. Whoo.

Mr. ARCHANGELI: OK, now I hear it. And it should sound like what?

Dr. BASGOZ: That whoo sound shouldn't be there at all. You should hear bump-bum, bump-bum, bump-bum.

KNOX: Archangeli has no heart symptoms. So his leaky valve wouldn't have been picked up if Dr. Basgoz hadn't noticed it when she did a routine physical. The doctor says at some point, he'll probably need a new heart valve.

Not only are doctors skipping the physical, they're not as good at recognizing problems when they're staring them in the face. One study shows American doctors are pretty miserable at detecting heart murmurs. And Basgoz says many young doctors don't understand why they should bother to learn other parts of the classic physical.

Dr. BASGOZ: I am definitely worried that the physical exam is dying a slow death.

KNOX: At Stanford Medical School, Dr. Abraham Verghese blames much of the trend on American doctors' love affair with technology.

Dr. ABRAHAM VERGHESE (Stanford Medical School): I sometimes joke that if you come to our hospital missing a finger, no one will believe you till we get a CAT scan, an MRI and an orthopedic consult. We just don't trust our senses.

KNOX: It's as though what machines tell you is the only information that counts.

Dr. VERGHESE: You know, we often spend so much time with that entity in the computer. I call it the iPatient, you know, like your iPad and your iPhone. And the real patient in the bed is often left wondering: Where is everybody? What are they doing? I sense that we're spending very little time at the bedside.

KNOX: At Stanford, they're really trying to make sure this doesn't happen. So their graduates have to master 25 different bedside exam skills, from feeling a spleen to testing ankle reflexes.

Verghese is convinced that doctors who know how to do physicals will pick up a lot of serious problems.

Dr. VERGHESE: My worst nightmare is that someone passes through my hands with a diagnosable, treatable condition that I missed because of sloppy technique.

KNOX: Some critics think Verghese is an incurable romantic. One of them is Dr. Bob Wachter at the University of California at San Francisco.

Dr. BOB WACHTER (University of California, San Francisco): If I only have 10 or 15 minutes to interact with a patient and I'm spending half of the time doing some of these physical exam tests and not spending enough time listening to the patient, talking to the patient, answering their questions, I don't know that I've gotten my priorities right.

KNOX: But Verghese says patients miss the laying on of hands.

Dr. VERGHESE: I always listen to language very carefully when people complain about us - and they complain a lot. And if you listen to the words people use, it's very often: He or she never laid a hand on me. He or she never touched me. He or she was hardly listening, and they were busy entering stuff in the computer.

KNOX: He warns doctors not to overlook what's really happening when they do a physical exam.

Dr. VERGHESE: If you look at the physical exam, you know, one individual coming to another, telling them things they would not tell their spouse or rabbi or priest, and then, incredibly, disrobing and allowing touch, I think our skills in examining the patient have to be worthy of that kind of trust.

KNOX: Verghese says the full ritual is necessary to establish that connection.

Richard Knox, NPR News, Boston.

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