The Importance of the Physical Examination

Physical ExamMedical Schools and residency training programs are beginning to realize that they must devote more attention to training young physicians in the skills of physical examination. In recent years the tendency has been to concentrate on the technology rather than taking a thorough history and performing a comprehensive examination. Abraham Verghese M.D., a chairperson at Stanford’s medical program has been instrumental in creating the Stanford Medicine 25 program which emphasizes 25 physical exam skills that all students must learn, demonstrate and then teach. Prior to the program Verghese felt that ,” If you come to our hospital missing a finger, no one will believe you until we get a CT scan, an MRI and an orthopedic consult.” Steven McGee M.D., of the University Of Washington School Of Medicine is author of a book on evidence based diagnosis based on physical examination. He believes a physical exam can be as accurate as technology citing instances where evaluating patients’ eye movements are as accurate as an MRI scan in differentiating vertigo due to an inner ear problem as compared to dizziness from a stroke. W. Reid Thompson M.D. of the John Hopkins Pediatric Cardiology Division launched Murmurlab, a website containing the heart sounds of 1300 people to train his students how to distinguish which cardiac findings require further evaluation and an echocardiogram and which do not.

These physicians believe tests lead to tests and more tests and may obscure the diagnosis when a simple physical exam might provide the answer. They cite examples such as the 40 year old woman in a Northern California hospital who was being evaluated for a blood clot to her lungs with a CT scan because she had extremely high blood pressure and was confused. A simple examination of her breasts which had not previously been performed revealed bilateral hard non moveable malignant masses which were in fact the source of her problems.

Not all leaders in medical education feel the need to teach physical examination more effectively. Robert Wachter MD, the father of hospitalist medicine and former head of the American Board of Internal Medicine disagrees and feels more time should be spent on developing critical thinking skills than on physical diagnosis. Dr Wachter is part of a movement to shorten medical school education and shorten residency training. He believes in educating new physicians in a much narrower specialty oriented manner. Under his influence and leadership the Internal Medicine Board Examination is now a separate exam for doctors practicing in hospitals and those practicing outside hospitals.

I have been a faculty member teaching medical history taking and physical diagnosis to medical students for over a decade at the University Of Miami Miller School Of Medicine and the Charles E Schmidt College of Medicine at Florida Atlantic University. These two institutions have managed to teach both critical thinking skills and excellence in physical diagnosis without shortchanging either skill. There is no reason to narrowly train doctors when the fund of knowledge and technology is dramatically increasing. The goal to shorten medical school and residency seems to be an economic goal designed to reduce the costs of education and training a doctor and produce a class of physicians who can be compensated at a lower level. If anything today our future physicians need a broader more comprehensive training to improve understanding and communication regarding the increasingly complex and aging patient population they care for.

Advertisement

DNA Test to Replace Pap Smear

DNAThe Pap smear or Papinicolou Cervical Cancer Test is designed to detect early cancer of the cervix. It requires expert technique in obtaining the specimen during a speculum pelvic exam, expertise in applying the swab obtained specimen to a glass slide and preparation of the slide for transport to a cytology lab for microscopic evaluation. The microscopic evaluation is supposed to be performed by a specially trained and certified cytologist but they are in very short supply. The result is that there is great variability and suspected variation of accuracy in this test.

We now know that cervical cancer is a sexually transmitted disease (STD) of the human papilloma virus particularly HPV strains 16 or 18. Roche Molecular Systems has obtained FDA approval for its HPV DNA molecular test looking for fourteen high risk HPV strains. If a woman is found to have strain 16 or 18 health care professionals are advised to proceed to testing with colposcopy. If one of the other strains is found it is suggested that a Pap smear be performed to screen for the need for colposcopy. The FDA approval came after testing 48,000 women and comparing the accuracy of Pap Smears versus the DNA testing.

The new FDA approval allows clinicians to use the HPV testing alone or in conjunction with Pap smears.