Are Physical Exams Just Theatre?

Learning the age old art of physical examination used to be an essential part of 1st year medical education. Not any more.

Technology has changed that. "We're now often doing expensive tests, where in the past a physical exam would have given you the same information," says Jason Wasfy, a cardiologist-in-training at Massachusetts General Hospital in Boston.

As a result, many doctors are abbreviating the time-honored physical exam -- or even skipping it altogether. Or, maybe they continue to do it, but for the wrong reasons.

1. In an editorial recently published in The New England Journal of Medicine, Drs. Ateev Mehrotra and Allan Prochazka explored the complex issues surrounding annual physical exams. In the name of improving “value” in health care, they argue that these routine visits should not continue.
2. Telemedicine is diffusing into the practice of medicine and much of the diagnosing and treatment is done without a physical exam or uses remote sensing devices.
3. Executive health physical exams have dubious value whether or not the physical exam in thrown in as part of the $5000 tab

Electronic stethoscopes might improve what doctors hear, but research still needs to be implemented to validate the digital stethoscope as a way to increase value or eliminating the need for additional tests.

Eko, a maker of high-end digital stethoscopes, has just received the first FDA clearance for its devices to use AI algorithms to automatically detect atrial fibrillation (AFib) and heart murmurs. Using this capability, primary care physicians, who are not nearly as extensively trained at spotting heart issues, will be able to identify potential cases of AFib, as well as valvular and structural heart diseases, with an accuracy similar to seasoned cardiologists.

The physician’s workflow remains practically the same as using a conventional stethoscope, except that Eko’s devices, which include a built-in single-lead ECG monitor, send their readings to a paired smartphone that displays what Eko’s AI thinks about the data

1. Stethoscopes carried by health care practitioners are loaded with diverse bacteria, including some that can cause healthcare-associated infections, according to a study. Maybe getting it off your neck is not such a bad idea after all.

6. While there are certainly examples of physical exam altering diagnostic accuracy, most medical students are taught “Listen to your patient; he is telling you the diagnosis.” Of course Osler said that over 100 years ago when he had more than 20 minutes for a visit, no EMRs , and no billing code compliance time sucks.

7. Even if you have a doctor use a stethoscope or perform a physical exam, it is unlikely that he or she will be competent to do it. Several recent studies document the decline in physical examination skills among physicians. When do you think was the last time your ophthalmologist or otolaryngologist used the stethoscope the drug company gave her at graduation?

8. Many physical exams are done so doctors can document they did them so they can bill for doing them even if they listen to your lungs through three layers of clothes.

9. Many physical exams are so perfunctory (shine a light in your throat and say "ah", put a stethoscope on your chest, feel your abdomen, strike your knee with a reflex hammer) as to render them useless and merely therapeutic theatre.

10. It is a last chance way to put some high touch into the visit.

Yes, the laying on of hands has some therapeutic value.

Just make sure you wash them. They might have coronavirus on them.

Arlen Meyers, MD, MBA is the President and CEO of the Society of Physician Entrepreneurs on Twitter@SoPEOfficial and Facebook,