A Country Doctor Writes:

Left to my own devices, I would be selective about when and how much of a physical exam I do: either not at all or very detailed for just those things that can help me make the diagnosis. I have no patience for boilerplate normal exams. Any doctor who uses the term PERRLA (pupils equal, round, reactive to light and accommodation) is probably faking it. First, most of the time this isn’t actually tested completely and, second, even if it’s done correctly, it has no relevance in the majority of chart notes I have found it in. I have actually seen it in office note templates for urinary tract infections!

It is well known that the history makes the diagnosis in the vast majority of cases. But that task – or art, actually – is sometimes relegated to support staff or forced into unnatural click boxes. Because reimbursement until very recently was tied to how many items were asked about and examined, there was a loss of the story, or narrative, of the patient’s illness. And you could get more brownie points by including things that were extremely peripheral to the clinical problem at hand.

EMRs make it easy to produce long office notes with lots of reimbursement and quality scoring points of uncertain clinical value and accuracy.

Specifically, the physical exam has in many instances become a corrupted, fraudulent, one-click travesty of the art and professionalism we swore an oath to hold high when we graduated from medical school.

The pandemic and the rush toward telemedicine made it clear to most people that medical diagnosis, advice and treatment is entirely possible without physical contact. It was just a matter of getting paid for it, or the healthcare industry would have come to a stop, or at least a crawl.

Now that we have admitted that listening, talking and a certain amount of looking or observing can be done without being in the same room, it is time for us to be honest about the value of the physical exam:

It is a ritual.

It is often irrelevant.

It is often done poorly.

It was exploited for reimbursement when cognitive work was undervalued.

Our medical education in universities and tertiary medical centers taught us how to handle complex and baffling cases that had eluded diagnosis in the primary care setting: Start from scratch, assume nothing. This is a method we need to use in select clinical situations.

But in everyday practice that is inefficient and unnecessary. Most of what we see is simple stuff and part of our job is to triage, to know when something seemingly ordinary is or has the potential to be more serious.

We need to know how to do a really good and relevant physical exam when the situation requires it. But we also need to know when that would add nothing and only waste our time and effort.

(“Routine physical exams“ for asymptomatic people are a separate topic. They have almost no proven value according to Choosing Wisely. Even clinical breast exams are not supported by evidence.)

Let’s embrace the new honesty about the value of our work:

Our work cannot always be measured by its comprehensiveness or by the time it takes. The sages people have sought out throughout human history all tended to be brief and to the point, which is part of why they have always been valued. They see the central issue more clearly. So should we as physicians. We need to know where to spend our effort.

The practice of medicine is cognitive work. The more skilled you are, the less you may need to fumble around to make a diagnosis. The better you explain and motivate, the less time you might need to initiate a treatment plan for each patient.

Televisits tended to take less time than in-person visits. Consider the implications of that in this era of purported physician shortages. It is part of the basic question: Where is our training and experience best used, performing ritualistic and pseudo-comprehensive exams or zeroing in where attention is needed?

I am not advocating telemedicine over in-person visits. Telemedicine can be convenient and practical, especially when you live hundreds of miles from specialists. But I am advocating a different view of the clinic visit in general:

Stop faking comprehensiveness. Have the courage and integrity to do only what the clinical situation requires. Don’t fill your visit or office notes with phony fluff. If you then have time left over, use it to relate to your patient as a human being, instead of a virtual/human checklist.