Friday, September 4, 2009

Doctors Mourn Physical Exam

Doctors Mourn Physical Exam

StopPagingMe. com, The Online Housestaff Community, reports on the waning physical exam skills of training doctors. Advances in imaging tools have been blamed for this phenomenon. Should we re-focus our teaching on the skills of yesteryear or begin to teach doctors the technological tools of the future?

(PRWEB) October 1, 2005

The physical exam is dying, but advanced directives are in the chart and no o­ne is rushing to the bedside.

While the old-schoolers pine for days of yore when a murmur was auscultated to the extreme, the young physicians rely o­n imaging modalities like CT scans, echocardiograms, Dopplers, MRIs, and even plain x-rays (which are also waning rapidly) to guide therapy.

StopPagingMe. com, The Online Housestaff Community, has developed into a cultish portal on the web for young physicians across the U. S. Their no-nonsense commentary on current medical topics and their ability to take the pulse of young doctors have won them thousands of supporters. In this article, they tackle the difficult subject of technology versus the art of medicine. While technologic advances makes patient care easier, more efficient and less subjective, physicians rely less and less on their physical exam skills to care for the ill. Are we failing our young doctors by not appropriately training them with the same techniques their forefathers used? Or, should we adjust our medical training to keep up with the times?

Attendings often lament about the housestaff’s inability to appreciate a murmur, and study upon study prove them right. As an example, Mangione et al., in the Journal of the American Medical Association, showed that internal medicine and family practice residents o­nly identified 20% of important and commonly encountered cardiac events. Even scarier, their level of training made no significant difference and medical students weren't much worse than residents.

So, housestaff are deficient with the stethoscope. But you know what? So is everyone else. Lok et al., proved it by showing that interobserver agreement, amongst experts, for the detection of S3 and S4 gallops was little better than chance.

The truth is, most residents couldn’t differentiate mitral regurgitation from aortic stenosis if there USMLE scores depended o­n it. Is that sad? Yes. Should we try harder to teach these skills? Maybe not. Times have changed and tools have changed with them. Why fight against the current and try to teach new dogs old tricks? When they invented the turbine engine for jets do you think the guys making the propeller planes cheered? Perhaps the physical exam is not dying, it’s just being replaced.

Modern technology is outpacing healthcare at an alarming speed and few efforts are being made to keep up. From rooms piled high with patients’ medical records to hand-written orders we are still living in the past when we walk into the hospital. So why would medical education be any different? Look at the average age of those who run medical training programs. They were trained when nurses still respected doctors; when discussing a patient’s illness o­n rounds could be done in the hallways; when the physical exam was the gold standard.

The truth is, imaging modalities like CT, MRI and ECHOs can give concrete answers and provide massive amounts of information in a much more timely manner. IÂ’m not advocating the abolishment of the physical exam altogether, but letÂ’s put it in perspective. ThereÂ’s a reason most emergency departments have CT scanners right next door and ultrasound machines in a closet close by - because they provide the most helpful information in the shortest amount of time. Unfortunately, our medical training has not reflected this change in management strategy. ItÂ’s time to change.

Past authors have proven that even experts cannot reliably agree o­n auscultory findings, so why should we expect interns and residents to be better. After all, they’ve grown up in hospitals where the majority of patients o­n a telemetry floor will get an ECHO before anything else. Their diagnostic gold standards are now based o­n imaging modalities rather than physical cues. So do we harp o­n the dying physical exam skills of medical students or do we adjust medical education to keep up with technology? Perhaps medical students should begin interpreting CT scans, MRIs and echocardiograms at an earlier stage. Wouldn’t it be great to have senior medical residents skilled in echocardiography so that when the ECHO tech goes home, the medicine resident can find out his patient has wide open MR or a massive pericardial effusion before 8am the next morning? I know this sounds crazy but wouldn’t that also restore some of the fun of internal medicine - learning skills that other specialties don’t have? Instead of ordering the ECHO, then calling downstairs to see if they received your order, then waiting for the tech to come by, and then waiting again for the study to be officially read, o­ne can imagine a world where medicine residents are instructed during their internship year to properly perform and interpret basic echocardiography. What a world that would be.

Is the physical exam a thing of the past? The o­ne of our fathers' generation is. Perhaps there is a more focused physical exam that will emerge in accordance with the technology that we now have at our fingertips. And perhaps as ultrasound machines, CT scanners, and MRIs become even more accessible, medical education will be forced to heed the call of technology and train its young doctors accordingly. Until then, medical students will endure long lectures o­n the S3 and a diastolic rumble that they will never need to hear because an ECHO will beat them to it every time.


1. Mangione S, Nieman LZ. JAMA. 1997 Sep 3;278(9):717-22.

2. Ishmail, AA et al. Chest. 1987 Jun;91(6):870-3.

3. Lok CE, Morgan CD, Ranganathan N. Chest. 1998 Nov;114(5):1283-8.