I am writing in response to the article “The Death of the Physical Exam” by Shari Welch, MD, FACEP (Feb. 2014). I note, with dismay, the continued justification for the present-day lowering of the standard of care expected of physicians. The physical exam is required to assist in diagnosis and not because it is needed for full reimbursement. I will not defend the yearly physical exam as an effective screening test. In the emergency department, the focused physical exam is necessary for the experienced practitioner to use this skill and the patient’s history to render unnecessary many laboratory tests.
The suggestion that the vaginal exam in someone with first-trimester bleeding lacks value is a good example of the disturbing trend to no longer emphasize physical diagnosis in some medical schools. The vaginal exam may show an abortion in progress, a bleeding endocervical polyp, a septic abortion, or an incompetent cervix. A normal exam (with the history of vaginal bleeding) might suggest a bloody cystitis or unsuspected bleeding from the rectum. Those who “could make it through their shift without a stethoscope” have not been trained properly, and Laennec and Auenbrugger would roll over in the graves, as would Osler.
Physicians without stethoscopes will not hear the rales of heart failure or the gallop rhythm, or feel the palpable thyroid and hear the irregular rhythm in the patient complaining of weakness. The contention that the urinalysis is superior to the physical exam is poor thinking: the history, physical exam, and urinalysis are complementary. When there is no fever and no costovertebral angle tenderness, pyelonephritis is less likely, and it points to the lower urinary tract. However, when abdominal tenderness is found, one may be looking at a gynecological infection soiling the urine or an inflamed appendix resting on the bladder causing white cells to be present in the urine. The Advanced Trauma Life Support course has eliminated the digital rectal exam from the pelvic protocol because the floating prostate or the prostatic hematoma will rarely be the main clue to a pelvic fracture or a transected urethra. The yield was almost zero!
The focused physical exam gives assurance to both the physician and patient. It is critical and should justify the laboratory test that is ordered. It has not, indeed, gone the way of the dinosaur.
Orzie Henderson, MD, FACEP Saline, Michigan