Can the physical examination save us from the dehumanization of medicine?

By ROBERT WACHTER

In last week’s NEJM, physician-author Abraham Verghese paints a disturbing picture of a medical world in which technology has morphed from tool to object, the patient relegated to a supporting role. To me, Abraham has nailed the diagnosis but not the treatment.

I had the distinct pleasure of getting to know Abraham when we both served on the board of the ABIM (actually I came to know his work 15 years earlier, when I reviewed his bestselling book, My Own Country, for the NEJM). Abraham is a romantic and a traditionalist, and in last week’s New England Journal piece he poignantly lays out a problem he has fretted about for years: namely, that information technology is dehumanizing the practice of medicine. Describing rounds with his ward team at Stanford, his new academic home (he was recently recruited there from the UT-San Antonio), he recalls:

When I stroked a patient's palm and caused a twitch of the mentalis muscle under the chin — the palmomental reflex — it was as if I were performing magic. Still, the demands of charting in the electronic medical record (EMR), moving patients through the system, and respecting work-hour limits led residents to spend an astonishing amount of time in front of the monitor; the EMR was their portal to consultative teams, the pharmacy, the laboratory, and radiology. It was meant to serve them, but at times the opposite seemed true.

Although the presence of such a portal doesn’t sound like a bad thing to me (it beats the hell out of the pager and the old Easter egg hunt looking for lab results and consultants’ notes), his observations about the impact of IT on the physician-patient relationship are salient and powerful. In characteristically limpid prose, he decries this “new way” of medicine:



The patient is still at the center, but more as an icon for another entity clothed in binary garments: the "iPatient." … The iPatient's blood counts and emanations are tracked and trended like a Dow Jones Index, and pop-up flags remind caregivers to feed or bleed. iPatients are handily discussed (or "card-flipped") in the bunker [the team’s charting room], while the real patients keep the beds warm and ensure that the folders bearing their names stay alive on the computer.

Although Abraham advances the usual pragmatic arguments about unnecessary testing and missed diagnoses, he is clearly troubled by something much deeper, more fundamental, for both doctor and patient. Regarding the latter,

Patients recognize how the perfunctory bedside visit, the stethoscope placement, through clothing, on the sternum like the blessing of a potentate's scepter, differs from a skilled, hands-on exam. Rituals are about transformation, and when performed well, this ritual, at a minimum, suggests attentiveness and inspires confidence in the physician. It strengthens the patient–physician relationship…

And for physicians,

…what is tragic about tending to the iPatient is that it can't begin to compare with the joy, excitement, intellectual pleasure, pride, disappointment, and lessons in humility that trainees might experience by learning from the real patient's body examined at the bedside. When residents don't witness the bedside-sleuth aspect of our discipline — its underlying romance and passion — they may come to view internal medicine as a trade practiced before a computer screen.

I’ve written (here and here) about how computerization “de-tethers” us from the need to visit the radiology department, the ward, and the patient’s bedside. And I too am concerned that our physical exam skills may be entering a death spiral – underemphasized by trainees who have never learned them and supervisors who can no longer teach them. (Let’s be honest – many of our physical exams are now perfunctory performances in a Theater of the Absurd whose audience is comprised of coders and insurers.) That can’t be good.

Yet by arguing that the physical exam will save us from what I’ll call “iPatient-itis,” I believe Abraham has focused on the wrong finding. Metaphorically, the patient does have a Boutonniere deformity, but the source of the fever is sepsis, not rheumatoid arthritis.

Years ago – well before electronic records and CPOE – one study showed that internists’ fundoscopic exam skills were sufficiently poor (~50% error rate) that their observations were no longer useful. I’d wager that the same is true of most of the findings that Abraham nostalgically cites, such as Roth spots, subcutaneous neurofibromas, and the palmomental reflex. Remember that Physicians of Yore learned to elicit and interpret these findings during eras in which they spent 100 hours a week in the hospital, the average patient stayed for 3 weeks after an MI, and they had few data to review and analyze other than that culled from their physical exam and a handful of rudimental lab and radiology studies. It seems to me that with everything today’s residents and students need to do and learn, the chances that we can revive the painstaking Oslerian physical exam are zilch, akin to the chance that we can resurrect the study of Latin in medical school.

Even if we could create a new generation of expert physical examiners, would it be worth the time and trouble? I doubt it. When I was a medical student, I spent a couple of months at London’s Brompton Hospital, the UK’s premier lung disease specialty hospital. Brompton physicians lavished attention on the chest exam – elegantly listening for whispered pectoriloquy and egophany, percussing for dullness, and palpating for asymmetric chest excursions. Such exams often took 10 minutes. Ever the spoil-sport, around Minute 8, I found myself wondering why we just didn’t get a chest radiograph. Not because the ritual wasn’t engrossing – and yes, even “magical” at times – but because at some point, all of this elegance has to be weighed against cold-hearted considerations of accuracy, reliability, inter-observer consistency, and the cost of time.

This is where my argument diverges from Abraham’s. In my zeal to bring physicians back into the patient’s room, I’d place 20% of the emphasis on performing and interpreting a good, thorough physical examination, and 80% on teaching and promoting superb communication skills – eliciting the history, describing prognosis, discussing alternative treatments, determining the patient’s attitudes about end of life care, and apologizing for medical errors, to cite but a few examples. These are teachable skills that will never go out of style, skills whose value won’t be supplanted by PET scan results and graphs of trended ANCA levels. And, to me at least, they highlight the patient-as-person and physician-as-humanist more than sticking a tuning fork on a forehead ever could.

Don’t get me wrong. Like my dear friend Abraham, I too am terribly bothered by the “iPatient”. But Abraham sees the physical examination as the essential vehicle to promote a set of core values – the physician-patient bond, the humanism of medicine, and the central role of empathy – and keep our focus on real-, not on i-, Patients. For the most part, I don’t.

(By the way, if somebody ever needs to stick a needle into my pleural space, please be sure they use ultrasound [performed by someone who knows what he or she is doing], not percussion, for guidance.)

Moreover, by emphasizing the physical exam as the reason for leaving the “bunker” to visit our patients, I’m afraid we risk having that reason discredited. As laboratory and radiographic tests get better and cheaper, the physical exam may compete poorly on the playing field known as Evidence-Based Medicine. If our rationale for coming to the patient’s bedside was to test for shifting dullness and a fluid wave, what do we do when we discover that these are terrible tests for ascites?

On one point, I’m sure that Abraham and I would speak as one: those of us privileged to teach the next generation of physicians must relentlessly promote human contact between doctors and patients. If we don’t, the forces of technology will gradually erode this special relationship, causing irreparable harm to both parties. 

So let’s ascultate and palpate when it makes sense to do so. And as long as we’re doing these things, we might as well try to do them well.

But I’d argue that the main reason to enter the room is to speak to the scared, ill human being in the bed.

And, more importantly, to listen.

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A happy and healthy New Year to you and those you care about and for.