Last week’s #JHMChat saw an all-star guest lineup including Drs. Adam Rodman, Zahir Kanjee, Laura McNamara, and Shane Warnock of Beth Israel Deaconess Medical Center debating the value of the routine daily physical exam – is it worthwhile or a waste of time? This question was recently debated in our Point: Counterpoint series and got our readers fired up on both sides of the issue.
Team Pro-Exam argued that performing the physical exam builds trust and credibility and that patients have more confidence in physicians who perform a more thorough exam. Dr. Hadmon commented that the exam represents an opportunity to build trust simply by communicating to the patient and family the purpose of our diagnostic maneuvers. Dr. McNamara reported that patients sometimes open this line of communication with questions like, “How do my lungs sound, doc?”
Communication is key to any relationship. Simply stating to a family what was done, findings and the purpose could pave the way for less resistance and trust to do your job.#JHMCHAT
— Reshon Hadmon, MD ? (@HadmonReshon) November 16, 2021
A1: sometimes my patients keep me on my toes and will promptly ask “how do my lungs sound doc?” if I forget to say. patients are looking to our exams and communication of our findings to know how they are doing #jhmchat
— Laura McNamara (@mcnamara_lc) November 16, 2021
Dr. Kanjee strengthened the argument that the physical exam builds trust, noting that patients’ perceptions of their primary doctor are correlated with the number of exam maneuvers performed. Dr. Unaka shared her personal experience of feeling “unseen” when her own physician did not attempt to do an exam.
A1 @futuredocs, fully agree. This paper shows (at least in o/p setting) pts expect exams and think higher of their docs who do more of an exam. #jhmchat https://t.co/8rm16Yjh4A
— Zahir Kanjee MD, MPH, FACP (@zahirkanjee) November 16, 2021
A1: My personal experience on the other side of the stethoscope, I felt unseen when a physician I trusted to take my concerns seriously did not attempt to do an exam. We have to be mindful of the implicit messages we convey to patients when we choose not to perform exams #JHMChat
— Ndidi Unaka MD, MEd (@NdidiUnaka) November 16, 2021
The opposition was united in their argument that sitting down and listening to the patient builds more trust than performing a daily physical exam. Dr. Kaminski similarly pointed out that doctors can establish a true partnership with the patient by sitting down and having a meaningful conversation. Dr. Shah took this one step further in noting that performing a “full but cursory exam can come across as just checking boxes,” which may be off-putting to our patients and erode their trust.
Yes and no. There are other aspects of our care that I think contribute more to that therapeutic relationship. Sitting down and listening (just as @AdamRodmanMD & @ShaneWarnockMD), IMHO buys more trust #JHMChat
— Charlie M. Wray, DO, MS (@WrayCharles) November 16, 2021
A1: A full but cursory exam can come across as just “checking boxes” so I do prefer some intent when I am the patient #JHMchat
— Samir S. Shah (@SamirShahMD) November 16, 2021
A1: One could argue that the traditional exam is more about establishing performative roles than about a relationship as partners. Sitting at the level of the patient and having a longer conversation is usually more fruitful than a rote undirected exam. #JHMChat
— Martin Kaminski (@martinkaminski) November 16, 2021
It was clear that Team Waste-of-Time did not support a wholesale elimination of the physical exam, but rather advocated for the exam to be used in a focused and purposeful manner. Dr. Shapiro offered another strategy to making the patient a partner in the doctor-patient relationship: ask the patient specifically if there is anything they would like the doctor to take a closer look at. He also encouraged narration, in which the doctor voices whatever they are doing or seeing during the exam. This serves to include the patient as a partner in the exam, reassure them, and let them know what their doctor is thinking. Dr. Barrett similarly noted that narration of the exam builds trust by dampening the power dynamic and encouraging the doctor to use patient-centric language, free of medical jargon.
This is critically important
In parallel, we as Hospitalists can always remember to ask to do an exam.
Better yet, ask if anything specific they would like you to have a close look at#JHMChat— Mark Shapiro, MD ?? (@ETSshow) November 16, 2021
A2:
Starts w/ narrationExplaining as you examine what you are doing/seeing/feeling.
Relate it to day before
“Your heart sounds totally normal”
“Oh good, your leg looks much less red than yesterday. Good stuff!”
Everything goes from there#JHMChat
— Mark Shapiro, MD ?? (@ETSshow) November 16, 2021
A2. It can be trust building if we explain what we see and don’t see and why it matters. Especially given power dynamics and how we often speak in ways that aren’t easily understandable to patients#JHMChat
— Eileen Barrett MD MPH (she/her) (@EileenBarrettNM) November 16, 2021
A more practical argument from this side of the debate was the harmful effects of waking patients early in the morning for a routine exam. Dr. Rosenberg noted that it can be dehumanizing and make a patient feel like a specimen to have a doctor wake them and remove their gown for a physical exam in the early morning. Dr. Aleman pointed out that we also interrupt prayer times, meal times, and time with family by doing unnecessary exams.
A3: i think its also more than sleep time. We could be interrupting prayer time, meals, important conversations with family members specially if were examining them múltiple times a day.
— María Jimena Alemán (ella/she/her) (@MariaMjaleman) November 16, 2021
We can really dehumanize a patient here. Waking a pt at 645, asking them to undo a gown, and listen to their lungs is not always patient centered approach, when that time could be spent sitting at eye level and allowing them to feel heard and less like a specimen. #jhmchat
— Noah Rosenberg, MD (@nsrosenberg) November 16, 2021
Perhaps the most succinct summary of the night came from Dr. Schultz saying, “If not done with a particular purpose, [the exam] can feel like mindless box-checking for documentation/billing purposes… Done well, it can strengthen the human connection between clinician and patient.”
A4: If not done with a particular purpose, can feel like mindless box-checking for documentation/billing purposes which contributes to burnout. Done well, it can strengthen the human connection between clinician and patient which is protective against burnout. #JHMChat
— Eric Schultz (@ericschul) November 16, 2021
Did you miss this #JHMChat? Don’t worry! Be on the lookout for information on our next chat.
I had many patients alluding to me that they like the fact they are being checked, and many others complaining that their doctors “did not even touch me.” I totally agree that physical exam can build relationships with patients, and I also strongly agree that “routine” daily exam can be unnecessary or even disturbing to patients when done in the wrong time and style. Patient might wonder why their physician check their belly every day when they are being investigated for ischemic check pain and they do not have “belly symptoms.” Also, physicians should know how much useful the exam maneuvers they routinely practice are in detecting and excluding disease by referring to evidence and guidelines. Kernig and Brudzinski’s signs, for example, can be uncomfortable to patients and their sensitivity and specificity are not the greatest anyways.
Communication between the doctor and patient is very important and doing exam to patient is also like drug. The treatment should start from this only. Good information given here.