You have just seen the last patient of the day with a medical student and the two of you begin to debrief. The student asks, with a puzzled look on her face, why you performed a back examination on a patient with chronic myofascial pain syndrome, a condition that causes tenderness at specific trigger points. How, the student demands, will this help, particularly as we already know the patient’s diagnosis and there is nothing new today that indicates a need for a back exam?
The student’s surprise is in keeping with the current way physical examination manoeuvres are taught. Physical examination manoeuvres are the specific tests conducted during a clinical appointment to investigate whether a patient has a given condition, using the physician’s senses and occasionally tools such as the stethoscope. In recent years, there has been increasing critique of some components of the physical examination, and their place in evidence-based medicine (EBM). Starting in 1992, JAMA has been publishing a series called the “Rational Clinical Examination,” which looks at the evidence behind how useful certain manoeuvres are in diagnosis. This series is part of a trend toward removing inconclusive and possibly misleading tests from the physical examination, such as the routine breast exam. Similarly, a campaign promoting EBM and judicious resource stewardship, Choosing Wisely, has de-emphasized the utility of the annual physical examination. This is due to research showing that the annual physical, when you are feeling just fine, is probably not going to help you stay well or live longer. Indeed, there are ongoing discussions of the ultrasound even replacing the stethoscope. In other words, the routine of doctors listening to patients’ chests at regular check-ups is becoming obsolete.
But isn’t there a role for “touch” in practice, even in the absence of diagnostic enhancement? The reasons for continuing these “unnecessary” examinations are less scientific, but their value may still be persuasively argued.
Patients routinely notice that there is less touch in medicine, sometimes complaining that a physician didn’t even “listen to my heart” although they may have had an echocardiogram performed that day. Consider a patient being followed by multiple physicians for a condition such as chronic pain, as described in the vignette. Perhaps the patient has been informed multiple times that they have a myofascial pain syndrome, but deep down they remain unconvinced. A physical exam can help a physician gain credibility in the patient’s eyes; it can be therapeutic in that it establishes a rapport, demonstrates attention to the patient’s body, and may help “earn” the physician the right to now reiterate their diagnosis. Patients place weight on this part of a clinical encounter, and when it is taken away (even for the most evidence-based reasons), it can leave a patient feeling short-changed. In Psychosocial and Spiritual Care: An Alternative Approach, Thurstan Brewan is quoted describing the clinical examination as demonstrating to patients:
“That they have not been abandoned, that the doctor is still anxious not to miss anything that could be corrected or prevented… blending professional efficiency with the age-old power of touch to give comfort; at the same time giving a clear signal to the patient that we don’t think of him as in any way repugnant, unclean or infectious.”
And, after all, couldn’t there be additional knowledge gained—beyond the scope of the system being assessed—through physical examination? It is fairly standard for a radiologist to end a report with the comment: “clinical correlation required.” Indeed, there is recognition of patient context in disease presentation and individual illness journeys. In other words, a test does not replace a doctor’s understanding of the unique aspects of a particular patient. This understanding forms physicians’ tacit knowledge of their patients, and is based on shared former experiences. When we know our patients, we notice subtle changes in their demeanour during examination, something that is difficult to articulate but that forms an important part of our clinical management. Maybe they show more anxiety during a certain component of the exam, which upon further questioning reveals hidden insecurities about a medical condition or prior trauma, which then would set the stage for an open dialogue and perhaps a management plan. It might be argued that additional, oftentimes unexpected, clinical knowledge might be gained when we separate ourselves from the “electronic” version of our patient and engage in the touch ritual. By depriving ourselves of this, might we be losing our intuitive clinical sense?
In addition to the trust and intuitive information that can be gleaned from the physical exam, it is also clinically useful to examine the patient in front of us, rather than rely only on external investigations. The patient in our vignette with acute pain on a background of chronic myofascial pain that is dermatomal (occurring only on one side of the body in a defined area), on examination may be found to have a zoster rash, or shingles, the discovery of which could alleviate unnecessary suffering.
To your medical student’s question about how examining the patient might change the management of her condition, you might say this: The act of touch changes the relationship, and this, in turn, affects everything.