Whither the physical exam?

JAMA just posted an online piece about the physical examination of obese patients. The gist is that all of our usual examination techniques are “undermined when the viscera and vasculature are enveloped in a thick layer of adipose tissue.” The authors call for improved training on the adaptation of physical examination to the obese patient.

The physician in me agrees that if the physical exam is of any value, we ought to be better trained to perform it on all patients, obese or not. But the hospital epidemiologist in me asks: how useful is the physical examination, and how often should it be performed in the acute care setting?

Consider what we know about the utility of the physical exam, the efficiency of pathogen transmission by direct contact, and the difficulty of achieving sustained excellence in hand hygiene (not to mention the disinfection of stethoscopes, coats, etc.). Is it wise to encourage multiple potential examiners (medical students, interns, residents, attendings, consulting physician teams, nurses, respiratory therapists) to have such frequent direct contact with acutely ill hospitalized patients?

I have alluded to this issue before, but in the spirit of this blog’s title (controversies), I’ll state the question more directly. Is it time to re-evaluate our physical examination practices in the acute care setting?

How important is the physical exam?

Most of us do parts of it each time we care for a patient. Aspects of the physical exam are included in several of our nosocomial infection definitions. Yet how good are we at performing physical exams anymore? How reproducible and reliable are physical findings (within and between observers)? How sensitive and specific for diagnosing illness, including infection?

I'll admit I've sometimes thought (usually when frustrated over low hand hygiene adherence) that patients would be safer if healthcare workers didn't touch them at all.

If this topic interests you, today's NY Times has an article on Dr. Abraham Verghese, who is passionate about "taking back" the lost art of the physical exam.