I have never been much of a proceduralist. In an admission of my own insecurity, the physical examination remains one of the few domains where I maintain a sense of professional skill and authority. 3 Only now have I come to recognize the examination as a ritual that is restorative and brings me calmness and confidence. Abraham Verghese has commented extensively on the role of the physical examination as ritual and its importance to patients he also has observed how this ritual brings physicians satisfaction through human connection. The quiet moments when I am listening to a patient’s heartbeat and breath can be centering, similar to the part of a meditation where one refocuses on one’s own breathing. The examination, though, is more than a tool that informs diagnosis and treatment. If I communicate that results of their lung examination are clear and that their oxygen saturation levels are normal, they often feel more reassured that they do not need medication. For instance, patients sometimes feel a need to use antibiotics to treat a respiratory infection. When patients and I disagree on a plan, the physical examination not only provides data, it also acts as an arbiter. If I had not been able to listen to his heart and lungs, and examine his jugular vein and lower extremities, I may have put too much weight on the patient’s lack of concern and missed the diagnosis. His examination suggested he was in heart failure. A patient recently came in feeling a bit tired but felt it was nothing, likely as a result of working too hard. I work in Maine, which has its share of stoics. What was less apparent to me before the pandemic was how a thorough physical examination provides a measure of objectivity that can help me rethink a patient’s narrative. A discovery of an irregular mole, a soft tissue mass, or a new murmur-I do not forget these cases, and I do not think the patients do either. In addition, many of us have cases where an unanticipated finding on examination feels as though it saved a patient’s life. I am not sure how I am supposed to distinguish central vs peripheral vertigo, diagnose otitis media, or determine if someone has orthostatic hypotension without examining a person in front of me. Many physicians would say that some diagnoses cannot be made without examining a patient in person. It is a means through which I pause and physically connect with patients, I demonstrate my knowledge and authority, and is a tool I use to persuade patients and reevaluate their narratives. But I now realize the other ways I use the examination to advance care and its significance to my own well-being. It is clearly needed at times to make a diagnosis. 1 More recently, my accountable care organization’s emphasis on increasing our volume of Medicare annual wellness visits, which do not require a physical examination, and recommendations from some groups against routine physical examinations in asymptomatic patients 2 has me second guessing why I examine healthy elderly patients.Īs our primary care practice has pivoted to telehealth and the physical examination has been ripped away from me, I find myself reflecting on what value the examination has. As a resident, the reams of information I had on patients before I stepped into their room made it tempting to do the “quick physical exam” that Robert Hirschtick bemoaned in a recently republished essay. In the 15 years that I have been a physician, the physical examination has always occupied a precarious space for me. What is a physical examination worth? As I stare at a list of my upcoming patient appointments in my primary care clinic and try to decide who shall come into the office despite the coronavirus disease 2019 pandemic, this question paralyzes me. Shared Decision Making and Communication.Scientific Discovery and the Future of Medicine.Health Care Economics, Insurance, Payment.Clinical Implications of Basic Neuroscience.Challenges in Clinical Electrocardiography.
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