Dr. Mason Greer and his colleagues at Case Western Reserve University with their portable magnet have made hand-held magnetic resonance imaging (MRI) devices plausible for medical diagnosis.1 That brings us one step closer to Star Trek’s, Dr. “Bones” McCoy’s tricorder which he will simply wave over a suffering individual and obtain an instant diagnosis 200 years from now. Before we get there, as we move down the path of higher and higher resolution organ imaging and diagnostic molecular biology, it seems reasonable to ask this question: “Of what remaining use is the physical examination in modern medicine?”

Some of us would rather not answer this question because of the pangs of guilt which emerge from our most recent patient encounters. It is doubtful that any of us began our practice of medicine intending only superficial interactions with our patients, but as a result of the crowded waiting rooms and with an eye on the clock, many of today’s physicians “evaluate” patients who remain fully dressed whom they may or may never even touch. Because this truth hurts, perhaps it is better ignored. Nevertheless, we believe it appropriate to confront this reality head-on and consider whether our ancient skill, handed down to us from the likes of Hippocrates, Galen, Laennec, Harvey, Sydenham, Osler, Taussig, Beeson, and Harrison has become outdated- - revered, but irrelevant.

We have been in the field of internal medicine for a combined 85 years as a solo-office- and community-hospital-based rheumatologist and academic infectious disease specialist, respectively. In separate practices we have participated in the management of thousands of patients, many of whom were born in the 19th Century. We have attempted to pass on what we have learned from our own professors to countless medical students. Admittedly, the patient encounters which characterize our specialties are more basic than most other internal medicine disciplines. Naturally, we rely heavily on our abilities in history-taking and physical examination and are most likely guilty of considerable hubris with respect to our “high-tech” colleagues in other specialties. It is important to point out that some of our assertions are based upon our own clinical experiences. Moreover, there are undoubted limitations to older references cited herein. This is especially true with advances in present-day diagnostic techniques. We apologize in advance for our bias and are open to the possibility that we may be more than slightly anachronistic as we attempt to assess the value of the physical exam.

It remains understood by most bedside physicians that the history is foremost in the evaluation process and the medical literature confirms that a likely diagnosis can be established in approximately 70 - 80% of individuals2–4 on history alone. The physical examination and the laboratory each yield the diagnosis in a rather paltry 10 – 15% of the time. Presumably, some combination accounts for the remainder.

General Observations

Because the “tools of the trade” in our specialties are few, we rely on the physical examination more heavily than some physicians might and we believe that its contribution to diagnosis is greatly underestimated. The diminished value is perhaps related to a commonly held perception that technologic tests – imaging and laboratory – are more objective and therefore more useful than findings on physical examination. In actuality, according to some authorities the physical examination equals the diagnostic objectivity of both imaging and laboratory results.5 When findings of well-done physicals by separate examiners on the same patient were compared, the inter-observer agreement on physical findings was equal to that of different radiologists interpreting the same image, be it chest x-ray, computed tomography, screening mammogram, angiography, MRI, or ultrasound.5 Similar results have been found for various endoscopies and interpretations of histopathologic findings by separate specialists in those fields.4 Rather unexpectedly, agreement on physical examinations by physicians was just as consistent as the interpretation of laboratory results.5 Thus, a careful physical examination turns out to be as reproducible as most of our technical tools for diagnosis.

The Physical Examination Today

In an editorial, Feddock6 noted and lamented the flagging performance of physical diagnosis by medical students and suggested that it was related to the lack of expertise in the art by medical school faculty. Their own lack of confidence in physical examination skills, the belief that other diagnostic pursuits have greater value, or the perceived inefficiency of “hands-on” medicine may explain, in part, why many of today’s teaching rounds are often held away from the bedside. At present, too many medical students never get to observe the professor examine a patient and vice versa. Reported physical findings from the emergency department physicians are simply endorsed without scrutiny by many admitting ward physicians. However, the inherent danger in such a practice was demonstrated in a study of 100 consecutive medical admissions through the emergency room to the inpatient service.7 In this investigation an experienced hospitalist identified 26 patients with significant physical findings that had not been noted by both the emergency medicine resident and emergency- room attending. The physical findings led to a change in the diagnosis and treatment of all 26 individuals– a forceful argument for the potential of a well-done examination. An academic internist and renowned teacher of medical residents recently described the intense surprise, interest, and appreciation of his young trainees as he closed the computer room and any access to images and laboratory results, spending the entire rounding time at the bedside, repeatedly demonstrating the unique value of a careful bedside examination yielding information obtainable in no other way.8

The Physician as a Sherlock Holmes

With experience, a good doctor can begin to depend on each of the five senses to strengthen, weaken, or add new directions to the diagnostic possibilities suggested by the history. For example, in the setting of a fever of unknown origin, the discovery of a faint diastolic murmur would ordinarily lead to a prompt echocardiogram. Such a pathologic heart sound might go completely unnoticed in a superficial cardiac exam and lead to yet another round of empirical antibiotics and further diagnostic obfuscation.

Given the number of patients most physicians have on their schedules for each day, time does not permit a compulsive examination of each patient as described in the leading textbooks of physical diagnosis. However, a carefully done history should point to one or, at the most, two organ systems as the probable source of the ailing person’s chief complaint. It would be difficult to fathom why a doctor did not have time to at least examine the involved system in a “world-class,” textbook fashion. For example, a chief complaint of dyspnea on exertion should lead to a precise count of the respiratory and heart rate the measurement of the patient’s blood pressure, as well as a visible inspection of the precordial area for the point of maximum cardiac impulse (PMI) and abnormal chest movements followed by palpation of the PMI and entire precordium. Percussion of the left anterior hemithorax could then predict the enlarged cardiac silhouette which imaging might later reveal. Armed with the history and findings thus far, systematic auscultation of the heart with the diaphragm and bell of the stethoscope including listening in the left lateral decubitus position should reveal the expected 3rd heart sound of cardiac failure, the pre-systolic gallop of poor wall compliance, or a telltale murmur–previously missed by other physicians. Ankle edema in such a breathless patient further confirms suspicion of heart failure.

The musculoskeletal examination especially complements the history of joint pain, but requires a purposeful and meticulous search for point tenderness, synovial thickening, effusion, or limitation of joint motion to further pinpoint the problem.

Physicians with the mindset of a Hercule Poirot, Jane Marple, Lieutenant Columbo, or Sherlock Holmes as they lay hands on a patient are much more likely to happen upon unexpected physical findings leading to a diagnosis not suggested by the history - i.e.–an enlarged, left supraclavicular node in a patient with unexplained weight loss suggesting metastatic gastrointestinal cancer, or in a smoker, a metastatic lung neoplasm; or an enlarged spleen pointing to a to a lympho- or myeloproliferative disorder. While the history prompts us to give more attention to that suggested system or part, an unanticipated physical finding may completely redirect the focus of the workup. Additional examples of this might be a Babinski sign, petechiae, pulmonary crackles or focal wheezes, a cervical, abdominal or femoral bruit, a dilated pupil, a breast mass, an abnormal deep tendon reflex, atherosclerotic, hypertensive, or diabetic retinopathy or other abnormal funduscopic findings, or a cardiac rhythm disturbance. The list is as long as the imagination, curiosity, skill, enthusiasm, and carefulness of the examiner.

Most symptoms of serious illness are accompanied by correspondingly abnormal physical findings. Thus, a negative examination may also have great value. For example, absence of a heart murmur in a febrile patient is strong evidence against endocarditis. In a worried patient whose complaints are not especially ominous to the physician, a well-done examination with no abnormal findings serves to both reassure the doctor and comfort the patient.

Each part of the human body presents many ways to be examined. The dedicated physician is happy to discover or learn about ways to improve – through variations of his of her own method with imaginative trial and error, or observing and discussing the technique of a colleague, particularly that of a subspecialist. A novel approach may also be described in a journal article. No detail about the physical examination escapes the notice of a doctor who is genuinely interested in improving (eg a better posture for using the ophthalmoscope, a more systematic way to listen to heart sounds, or proper positioning to elicit subtle deep tendon reflexes. A well-done examination is very “physical”, with the physician pushing, pulling, and probing, at times with considerable vigor as well as some unavoidable discomfort to the patient. In the pursuit of excellence, motivated clinicians can be likened to highly trained athletes or musicians who never cease looking for ways, no matter how trivial, to discover the cause of a patient’s complaints or to exclude serious disease.

The astute examiner always assumes the same disciplined posture during each particular segment of the examination for maximum attention and concentration on that body system. This disciplined approach particularly helps preserve the quality of the examination when a physician is fatigued or pressed for time. There are certain conditions for improving success. One of the most important is that the patient should completely disrobe except for undergarments and wear only a covering gown. The abbreviation “WNL” should never stand for “We never looked.” A quiet, comfortably warm room with an examination table with capability for a pelvic examination is optimal. Bright, but controllable light best allows the option for darkness for the examination of the optic fundi. Privacy is essential (with ready availability of a chaperone for patients of opposite gender) so that the patient has the physician’s undivided attention during the examination.

An important and understated effect of the physical examination is the recognition by the patient of the doctor’s unique role in this human exchange – their physician meaningfully but respectfully touching and exploring even the most private parts of their body. This establishes the legitimacy of the doctor in the patient’s eye as no other aspect of the relationship does and separates the physician from other “healers.”

A carefully done physical examination necessarily adds considerably to the time spent with a patient. However, third party payers often set a fixed reimbursement for each visit. For the physician who desires to be thorough, fewer patients will be seen producing less income for the practice. The negative impact on the bottom line affects not only the conscientious or compulsive doctor, but partners and office staff as well. This conflict can threaten the quality or the very existence of the physical examination and has to be balanced by the obligation each physician feels toward the patient, striking at the heart of what it means to be a doctor. One somewhat less than satisfactory compromise for a busy waiting room would be to examine while the patient gives the history. Even if only slightly distracted in the process, the physician in a hurry may miss small, telltale clues to the diagnosis – an altered facial expression, or a slightly hesitant or evasive answer to certain questions. Looked at from the examinee’s perspective one might ask, "How attentive can a patient be to questions while undergoing simultaneous, vigorous manipulation?

Physical examination skills can be perfected over a lifetime or lost from disinterest and disuse. The pressure many physicians feel to see more paying patients rapidly and efficiently almost certainly contributes to waning examination skills or cursory assessment, but the decline is more likely multifactorial as administrative duties, pages, and phone calls mount and physicians age, suffer burnout, or simply become immersed in the complexities of family and social life.

Given the current emphasis on evidence-based medicine, large, randomized studies or meta-analyses consolidating data from hundreds of patients are needed to evaluate the utility or futility of physical diagnosis in modern patient care. However, the ultimate reliability of such information will still depend on one physician accurately examining one patient.

It follows that a patient deserves such an exam from a trusted physician. Indeed, the physical examination arguably should be among the bedside doctor’s finest professional skills. For us, it remains very rewarding – and challenging. We are open to the possibility that in the future imaging will decrease the need to lay hands and eyes on a patient. It seems unlikely, however, that pictures on a hand-held device or computer screen, however sophisticated, will ever be able to replace a compassionate interview and meticulous examination by a caring physician who is genuinely interested in their well-being.

Ethics approval

Not applicable—Editorial Commentary

Availability of data and material

Not applicable–Editorial Commentary

Competing interests

The authors declare that they have no known competing interests or personal relationships that could have appeared to influence the work reported in this paper.

Funding

None—Editorial Commentary

Authors’ Contributions

Dr. Fisher made all revisions. Dr. Handy is deceased.

Acknowledgements

None