2 March 2020
When it comes to diagnostics, few elements are as crucial to finding an accurate diagnosis than the physical exam. By looking for anatomic findings through palpation, percussion, observation and auscultation, physicians can gather about 20% of the data they’ll need to make an accurate diagnosis and treatment plan.1
Yet, as diagnostic tools continue to evolve and expand capabilities, the perceived importance of the physical exam steadily declines. In fact, in a survey examining causes behind medical errors and adverse events, about 68% of the physicians surveyed reported failure to complete a physical examination.2 In 76% of these cases, this oversight resulted in a missed or delayed diagnosis.2
While there are instances where diagnostic scans like CT scans and MRIs are crucial for accurate diagnosis, insights gained from physical examination are still highly valuable. As technology’s role in diagnostic medicine continues to expand, the question remains: Does technology hurt or enhance the physical examination?
One of the first things medical students learn is how to perform a thorough physical examination, and how to identify symptoms to make accurate diagnoses. Despite the physical exam’s central role in medicine, many medical students and practicing physicians don’t fully appreciate the value of a physical examination as part of the diagnostic process. For medical students specifically, this mindset contributes to a lack of confidence in physical examination skills.
In fact, one study found that students’ self-confidence in their physical examination skills hardly increased with each year of training. It cites a lack of textbooks and syllabi that explicitly distinguish between examination techniques with proven clinical utility and those without as the main culprit.3
As physicians lose confidence in their ability to spot symptoms during a physical exam, the more they’ll rely on CTs and MRIs to reach an accurate diagnosis. Patients that undergo these tests often experience more discomfort, wasted time, worry and stress—not to mention the significant financial burden these tests sometimes place on the shoulders of patients and the healthcare system in general. In this way, these tests may instead contribute to a decline in the patient experience.
For example, by visualizing Spontaneous Venal Pulsations in headache patients, as can be done with wide-view ophthalmoscopes, clinicians may be able to allay patients’ fears of scary diagnoses like brain tumors or elevated intracranial pressures—and save patients time and money.4
The physical exam continues to be a crucial first line of defense in the diagnosis and treatment of multiple conditions. Therefore, this over-reliance on diagnostic techniques beyond the physical exam may actually contribute to poorer patient outcomes and more missed or delayed diagnoses.
Consider a recently published study comparing physical and nonphysical diagnostic techniques, which found that physical diagnosticians were able to more accurately diagnose certain conditions than clinicians relying solely on imaging studies.5
According to the study’s authors, the key to determining the best route for diagnosis is analysis on a case-by-case basis: “Given the emphasis on healthcare costs, physicians and teachers must compare physical and nonphysical diagnostic techniques rigorously to select the best, safest and least expensive diagnostic test for each clinical situation.”
Rather than treating technology and the physical exam as mutually exclusive, can physicians achieve better patient outcomes by augmenting their own physical exam skills with technology?
Technology that integrates with the physical examination is perfectly positioned to enhance rather than hurt a physician’s ability to build a rapport with a patient. Advanced diagnostic tools like advanced otoscopes and ophthalmoscopes—which include features like wide-view optics, digital imaging and improved illumination technology, for instance—augment a physician’s diagnostic skills without creating a barrier between them and their patient.
Consequently, certain types of technology can improve patient outcomes while allowing clinicians to spend more time interacting with patients, especially within the context of a physical exam.
Physicians can learn to blend the old and the new, the physical and the digital, to enable earlier diagnosis and treatment within their practice. Using technology for certain types of diagnoses (those which data shows are more accurate when using technology) can enhance physicians’ confidence in their physical exam skills. Using technology wisely may also expedite the time spent on diagnostic testing so doctors can spend more time speaking and engaging with their patients.
Technology can be a powerful tool to streamline diagnosis, increase patient comfort and enhance the patient experience overall. The key to striking the right balance is seeing technology as a way to augment a clinician’s expertise and skill, not as a replacement.
1. Verghese, A., MD, Charlton, B., MD, Kassirer, J. P., MD, Ramsey, M., MD, & Ioannidis, J. P., MD, DSc. (2015). Inadequacies of Physical Examination as a Cause of Medical Errors and Adverse Events: A Collection of Vignettes. The American Journal of Medicine, 128(12), 1322-1324.e3. Retrieved April 26, 2019.
2. Mangion, S., & Nieman, L. (1997). Cardiac auscultatory skills of internal medicine and family practice trainees. A comparison of diagnostic proficiency. JAMA, 278(9). Retrieved April 26, 2019.
3. Wu, E. H., MD, Fagan, M. J., MD, Reinert, S. E., MS, & Diaz, J. A., MD. (2007). Self-Confidence in and Perceived Utility of the Physical Examination: A Comparison of Medical Students, Residents, and Faculty Internists. Journal of General Internal Medicine, 22(12), 1725-1730. Retrieved April 26, 2019.
4. Fitzgerald, F. T. (1990). Physical diagnosis versus modern technology. A review. The Western Journal of Medicine, 152(4), 377-382. Retrieved April 26, 2019.
5. Tai-Seale, M., Olson, C. W., Jinnan, L., Chan, A. S., & Morikawa, C. (2017). Electronic Health Record Logs Indicate That Physicians Split Time Evenly Between Seeing Patients And Desktop Medicine. Health Affairs, 36(4). Retrieved April 26, 2019, from https://www.healthaffairs.org/.