Can the Physical Examination Save Us From the Technology-Induced Dehumanization of Medicine?

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.

****

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

14 Responses to “Can the Physical Examination Save Us From the Technology-Induced Dehumanization of Medicine?”

  1. jfsucher January 1, 2009 at 8:42 pm #

    Thank you for another excellent blog posting. I completely agree with your points.

    1. Technology in and of itself is not the problem. Technology has afforded us more reliability and rapidity in our diagnoses. Our society does not accept missed or delayed diagnoses. And there is no room for “I am the doctor and the diagnosis is ‘X’ because I say it’s ‘X'” kind of attitude. I have written about imaging modalities for the surgical abdomen, commenting on the incredible usefullness of radiologic studies that now have significantly decreased the rate of “exploratory” or “non-therapeutic” laparotomies. I can’t remember the last time that I took a patient for an appendectomy who didn’t have acute appendicitis (when I started it was told to us that you had to have a 15% negative appendectomy rate, otherwise you were not a good surgeon. Bah. I don’t want to have someone cut me open or give me a drug I don’t need if there is a non-invasive way of proving that I don’t need a given therapy.).

    2. Communication IS the heart of a good physician. I tell my residents and students that they will not only learn the practice of surgery and critical care, but they will learn how to communicate. I lament on how incredibly poor we are at teaching language skills. Our profession is riddled with poor language. Such as, “Past Medical History”. Is there a Future medical history? Or “the patient has no white count”. “Really?” I respond. “No white count? Or do you mean that the patient does not have a leukocytosis?” If we can’t communicate well with each other, then how do expect to communicate with our patients?

    3. Listen to the patient. In surgery, 80% of the diagnosis is in the history. The rest is physical exam and technology. I can’t quantify how much of each because you do need to have a good history with at least a satisfactory exam to then request the correct test. But it’s that technology that will cinch the diagnosis with high reliability.

    Bravo to you Dr. Wachter. The key to our profession is better communication. Both between ourselves and with our patients. Let the technology continue to flurish and improve, and let us use the technology well. This is a show of true compassion.

  2. DZA January 2, 2009 at 12:05 am #

    PE over-rated. Time spent with patient, doing just about anything really, under-rated. I do variations of a directed PE somewhat for show (think E&M bullets), but more for the physical contact.  And for the ritual that is in it.  And occasionally for a pertinent sign (after a quick-sifting Bayesian analysis of potential encounter-specific physical signs, and whether said signs ((or lack thereof)) is likely to be helpful or actually counterproductive). That is, if I have not already detected most of the more useful signs by simple crass observation near the bedside. Notice I say near. Expert theory, and my own availability heuristic, suggests I already have pattern recognition wetware running in my head as I enter the room. The digital revolution is a given. The cyber revolution is what gives Dr Verghese the willies, I suspect. When can I start phoning it in…..http://www.msnbc.msn.com/id/4946229/?

    And the palmomental reflex seems a weak limb (http://jnnp.bmj.com/cgi/content/abstract/73/2/113) on which to hang one’s hat…

    Now i have to go check mine….

  3. DZA January 2, 2009 at 12:22 am #

    Re: utility of palmomental reflex. correct link is here…http://jnnp.bmj.com/cgi/content/abstract/73/2/113.

    now i have to go check mine….

  4. menoalittle January 2, 2009 at 6:17 am #

    Bob,

    Thank you for examining the iPatient. Indeed, physicians are abdicating the foundations of the profession and in one click, that quick, the patient is ignored and neglected. The generation of recently trained physicians seem to be more comfortable communicating with the HIT icons whereas the generation of decades ago trained physicians seem more comfortable communicating with patients. The highly wired hospitals, darlings of the government, HIT companies, and of the media, leave physicians (and nurses) little choice but to tether and tend to the terminal and work the clickers and keyboard, filling in silos of grids.

    The patients are neglected; the computer is not. When entering important data on the HIT instrument to enable “healthcare transparency”, who has time to get to know the patient or to find out he/she collapsed in the bathroom?

    One highly wired innovative hospital plans on using color coded gowns to more easily identify patients with certain “at risk” illnesses (not sure what color bracelets it uses to id DNR), and trained search dogs to find patients who get lost in the hospital. What a brilliant idea! Next, we will see signs on doors to patient rooms to alert computer clicking healthcare workers, “please examine me, I am sick”.

    Best regards,

    Menoalittle

  5. Brad F January 2, 2009 at 11:03 am #

    Hi Bob
    I was just discussing this article with my colleagues two days ago and we drew the same conclusions: romantic, but often outdated approach. JAMA’s rationale clinical exam series is always so enlightening in this regard, ie, DOES THIS PATIENT HAVE ASCITES or IS THIS PATIENT HYPOVOLEMIC, etc., always gives me pause. My thoughts always drift to, huh, why am doing this maneuverer again? Better yet, the same way I ask if the U/S will change my mgmt, I also ask if the stethoscope will do the same. In most cases no. EBM works both ways.

    I find more and more, the majority of my teaching rounds focus on questions along the lines of, tell us what living with sickle cell is like in high school, or what makes you “famous,” etc., and not, lets have a comprehensive bedside dissertation on S&S of PE, CAP. The discussions are more interesting, engender more doc-patient understanding, and help more than looking at say, bed elevation for distention of the IJ (or wait, is that an EJ)……and oh, the BNP = 800.

    Anyway, the naysayers could have a cynical response, and rightfully so, but I feel very comfortable with the flesh-based “iRevolution,” so long as patient centeredness is not competing against Apple’s next nifty piece of hardware or Msoft’s killer app. That would be awful.

    Brad

  6. chris johnson January 2, 2009 at 4:25 pm #

    “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.”

    That’s exactly right, Bob. The physical exam still matters, though, in what I do — critical care. One of the interesting paradoxes of critical care is that, high tech as it is, one often sees the first signs of trouble or improvement just by looking at the patient. Thus one of critical care’s most important activities is the lowest of low-tech. It took me a decade or so to really grasp the implications of that fact.

    In my experience, one of the key activities of going into a patient’s room to talk to a family is to SIT DOWN. Wonderful things happen when you see a person at eye level. That’s pretty low-tech, too.

  7. TribbleD January 2, 2009 at 5:00 pm #

    Fascinating presentation of the dilemna of modern medicine: the boundary between technology and clinical skill. I have been through the change to electronic record-keeping in two hospitals, my office and a hospice agency. I have a few observations:
    – so far, I have yet to see a product that lives up to the true potential of electronic medical record keeping. That said, the amount of available data and the speed of retrieval of data is indeed superior in most high-end systems
    – the nuances of the palmo-mental reflex aside, there are numerous situations where the quickest and least expensive route to the diagnosis lies in perfomance of a history and physical exam. As one who has spent the last 16 years as volunteer faculty teaching family practice residents in two hospitals, I am concerned that new physicians so rely on the technology that they haven’t enough clincal skill to know when the technology is giving them an answer that cannot be, and they see that clinical skill as being anachronistic.
    – the physicians who spend all day looking at the terminal instead of the patients are, in general, the same physicians who never elevated their gaze out of the paper record. The kind of medical relationship building described in your blog requires intentional behaviors in order to occur. New technologies tend to divert attention for a while, but physicians who are actually interested in the well-being of the patient will find the time to put the computer down and talk with, examine, and otherwise interact with the patient. Those habits must be developed in training or they will largely not occur later.
    – reflecting back on the first point, we physicians have been techno-ignorant enough that we accept the limitations of the products offered to us without question. There are no programs out there now that truly bring the power of computing to physicians in the manner that commercial systems to do the average checker at K-Mart. Perhaps it is time we started being more demanding on these systems.

    David B. Tribble, MD ABHPM FAAFP

  8. mchwistek January 2, 2009 at 5:00 pm #

    Bob,

    Technology creates an illusion that everything can be solved through its means. It is a spell that many of us physicians, unfortunately fall under. This misbelief has catastrophic consequences as it caries over to patients’ world where it morphs into a monster of gargantuan size raising its ugly head every time when someone’s life cannot be saved or eternally prolonged.

    Communication – and I could not agree more – is at heart of patient –physician relationship. Physical exam with its ritualization and symbolic power of healing is an excellent entry into the start of a relationship. There is something deeply intimate about it, for getting to know someone’s body we get to know his/her life story. It fosters understanding and empathy.

    Best regards,

    Marcin Chwistek

  9. geriatricdoc January 3, 2009 at 5:35 pm #

    Technology exemplified here by the EMR has been designed to help us communicate better, prescribe more safely and record our observations more rapidly so that the data can be shared by others also caring for the patient. All these attributes of the EMR are praise worthy and should be encouraged.
    Unfortunately, the EMR has encouraged certain medical practices that should cause all practicing physicians grave concerns.
    I report on practices prevalent in my medical Group which uses an EMR.
    Some physicians believe that they can increase their “productivity” by having their medical assistants input the patient’s history. History taking is often more relevant than the laying of hands and not infrequently this practice has led to the corruption of the patient record and is the origin of incorrect decisions and investigations. “Garbage in, garbage out”
    Dr. Wachter is critical of the duplicate nature of notes on a patient seeking care in a chronic care environment. That is a concern but also a reflection that the author of the note has not taken the time to edit it. Further, drop down menus that facilitate charting are time saving. However, if the user is not diligent enough to edit them appropriately they can be a source of serious error.
    They may reflect the absence of symptoms that were never inquired about and clinical findings positive and negative that were never elicited. These can be a source of significant error in the later care of the patient.
    Why do we allow this to occur? I believe that this is because of our current reimbursement system that rewards the note that has the correct bullet points to justify a billing code more than it justifies honesty in examination and effort.
    A mentor of mine decried the changing times long ago arguing that “Medicine was and art, not a science”. Dr. Verghese belongs to that school. I would like to paraphrase that physician and add that “Medicine is neither and art, not a science but a business” and that we have inadvertently created our professional versions of Bernie Madoff.

  10. davisliumd January 5, 2009 at 7:01 pm #

    Dear Bob:

    As usual, you nailed the challenges and the opportunities in practicing in today’s world of medicine.

    Two excellent points – “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.” Certainly if you were successful, would it be possible to increase the depleted ranks of primary care doctors, the backbone of any successful healthcare system?

    The other – “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.” Students look to their mentors. I was fortunate to have residents who were attending physicians from India and Pakistan who had extraordinary history taking skills, deduction, and physical examination techniques which help decrease the number of inappropriate imaging studies, labs, interventions. It seems that increasingly medicine both doctors and especially patients are focused on test results as if those were the truth rather than the context the results are place.

    Keep up the thoughtful inquiries. All the best to you and your family in 2009!

    — Davis Liu, MD

  11. Stagnaro Sergio January 19, 2009 at 9:19 pm #

    I appreciate blog topic, to which I have been dedicated my 53-year-long researcher activity (See my website). Today’s technology is clearly useful, but to often it is also distressingly terroristic. For instance, I mean that, ignoring quantum biophysical semeiotic constitutions and INHERTIED Real Risk of common disorders, including cancer, brings about jatrogenetic psychological terrorism through prescription of blood level oncological markers, NMR, biopsy, a.s.o, to individuals negative for Oncological Terrain (http://blogs.nature.com/nm/spoonful/2008/04/stress_as_a_therapy_1.html#comments). Finally, the End of clinical Medicine is the END of Medicine.

  12. Eugene C Corbett Jr MD February 2, 2009 at 8:55 pm #

    Expertise in clinical judgement will always require that the physician be a keen observer of both the subjective world of the patient and the objective world of physical reality, high tech AND otherwise (physical examination). Particularly in the primary care world, such preferred and more discriminating clinical judgement is best based upon keen observation and an eye for subtle and informing physical abnormalities. Sadly, more recent generations of physicians are becoming less trained in basic clinical observation skill as they learn in the high tech inhospital environment where the latter seems less important and is taught less. Less discriminating physicians spend more health care dollars on unnecessary tests and procedures, one of the most costly elements of US health care.

    Let’s be evidence-based. But let’s not throw our the baby with the bathwater!

  13. Bob Wachter October 23, 2009 at 12:16 pm #

    Abraham has another piece, building on the same themes, in a recent issue of Health Affairs. Interestingly, in the newer article he now emphasizes the ritualistic aspects of the exam — particularly the meaning of the “touch” — more than its practical value. He and I have discussed this issue (and he has read this blog post) and I wonder whether these discussions have influenced his thinking a bit. In any case, it is a provocative and beautifully written essay, as one would expect from this superb writer and thinker.

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