Physical Examination for Asymptomatic Adults? (NEJM)

This weeks New England Journal of Medicine has an article titled Physical examination for asymptomatic adults.

It describes a clinical scenario where a 60-year-old male presents for a routine visit with normal vital signs, up-to-date screening history and no concerns or symptoms. I think we all know that the evidence favoring in depth routine physical exams in people with a negative review of symptoms is by now fairly nonexistent. But the article includes opinions from two different doctors about the overall benefit, including which approach Fosters the best Doctor, patient relationship.

Allan Goroll, MD writes in favor of doing an exam. He summarizes:

Time is in short supply in modern clinical practice, particularly in primary care. Reducing low-value administrative tasks to free up time for a 10-minute thoughtfully directed physical examination that generates trust, addresses concerns, and picks up potentially important findings warrants serious consideration. The payoff in terms of relationship building, patient satisfaction, and risk reduction represents an excellent investment in time.

My eminent fellow substacker, Adam Cifu, MD, writes in favor of not doing an exam. He says

Forsaking the routine physical examination will be difficult because it has become a standard part of an annual visit and is expected by patients. There is, however, precedence for abandoning common practices when their clinical value is deemed to be marginal. Routine prostate examinations, pelvic examinations when Papanicolaou (Pap) smears are not warranted, and testicular examinations have been abandoned. We should focus on providing patient care that is necessary, evidence-based, and value-based, instead of care that is expected but potentially harmful.

I am a stickler for not doing a physical exam during a Medicare Annual Wellness Visit, because it was never meant to include an exam. If a patient raises concerns that require attention during that visit, which normally is free, they will have a bill for what amounts to an additional service.

During routine visits for a medical problem or with a new patient I have to confess I do at least a limited exam. My personal belief and opinion, as well as experience, is that patients more or less expect it and I do believe it helps establish rapport. It also adds to the perceived value of the visit. The literature now less and less supports doing much of a physical exam during routine visits, but the literature also has established very clearly that the patient’s trust in the physician greatly impacts the success of any prescribed treatment.

Here are a couple of pieces I have published before about doing an exam on your patient, in large part to establish the clinical scenario and the trust it can build. I have also included a piece about a life-saving auscultation of the carotid arteries on a high risk person.