Abraar Karan: Has the physical exam had its day?

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Abraar Karan (an internal medicine resident at the Brigham and Women’s Hospital) shares a fascinating opinion piece in the BMJ.

“The physical exam needs to change to make the most of technological advancements, says Abraar Karan. I received my first stethoscope from my mother, a psychiatrist who unsurprisingly had little use for the maroon instrument. I remember thinking that I wanted to be the doctor who knows how to use this better than anyone else. I went through clinical rotations paying close attention to the signs on a physical exam that could help secure a diagnosis for my patients. As a resident, I keep that same maroon stethoscope snug around my neck—yet for most of the day, I find I have little use for it”

It stuns me that in 2018 the stethoscope is still the piece of technology that defines the persona of a Doctor. One of my biggest hopes is that by launching 3GDoctor (ten years ago!), writing this blog and lecturing at some of the world’s best Medical Schools I’m helping to start a change so that in the future medics in training will ‘want to be the Doctor who knows the most about their Patients BEFORE they meet with them and is inspired to want to be better than anyone else at signposting their Patients to quality information’.

Related: With your access to the internet & my medical degree imagine how we could work together?

“I’ve found that the physical exam is essential when I’m evaluating a sick patient who is decompensating, but less so in routine day to day care. When I was an intern, one of my jobs in the morning was to see the patients before the rest of the team and to report my findings on rounds. For most patients, I began to notice that their exams were largely unchanged from previous days—to the point where the clinical presentation quickly became a simple declaration of “unchanged from yesterday,” before I presented laboratory and imaging data”

It still stuns me how little interest Hospitals have in documenting how Patients feel. We’re seeing hospitals like University College London spend £400Million on an EPIC Electronic Healthcare Record and the idea of Patients even seeing the record (or adding information to it) is not even an after thought.

I wonder how many Patients would agree with the statement ‘Unchanged from yesterday’? Imagine the enormous big data opportunities to earlier detect health issues if Hospitals could analyse self reported symptom information?

“The physical exam alone can rarely obviate the need for more testing in cases where a patient has any other compelling findings from either their history or routine labs. For instance, a patient who I admit with fever and a cough will be better evaluated by a chest x ray than by my auscultation of their lungs with my stethoscope. In fact, even if my exam were to be completely normal, we would still send them to the x ray machine—and if that was normal and the patient became more ill, we would probably upgrade to a CT scanner.

Similarly, if my exam was abnormal—say I heard crackles or minimal breath sounds—I would still, in most scenarios, send the patient for additional imaging. This is to say that the physical exam, which in the past would be the central part of a doctor’s visit with a patient, is now largely an additional data point that is usually, if not always, trumped by more objective, machine generated data, including vital signs (measured electronically), laboratory values (complete metabolic panels, complete blood counts etc), and diagnostic imaging (x rays, CT scans, ultrasounds, MRIs, PET scans, and more)”

This is quite an amazing example of how defensive medicine has become and the reliance Doctors have on imaging results before they’re confident to give a diagnosis.

“Don’t get me wrong—there are still a number of situations in which I find the exam to be clinically essential, and it certainly has a solidifying effect on the doctor-patient relationship, but there needs to be a major shift in how we examine our patients to make the most of technological advancements. One of the key problems with the physical exam is the wide range of variability between doctors. That is to say: two doctors may look at the same patients and have two different interpretations of the exam. Yet this happens with less frequency when using other diagnostics, including advanced imaging such as bedside ultrasounds”

I think the key problem is in 2018 Patients all too often meet Doctors who know little/nothing about them and how they are feeling right now. I think most senior medics don’t realise that when someone clicks on an advert on the internet the advertiser often has more information (supplied by Google/Facebook etc). The major Cancer Charities are experts at using data in devious ways to get donations out of Patients with Cancer and their Families and Friends.

“One example that should be particularly familiar to most doctors is estimating a patient’s jugular venous pressure (JVP) by visual inspection—a common poor man’s diagnostic in heart failure management. Studies have shown that physician estimates of JVP vary widely by the examiner, making the clinical finding hard to truly rely on. And we have increasing data to suggest that for some measures, bedside diagnostic equipment is superior: in a study of internal medicine residents, those who used handheld ultrasounds to assess right atrial pressure did so correctly 90% of the time, versus only 63% of the time in those who did so by physical exam of the JVP. As bedside ultrasounds become cheaper, we will see far more in clinical practice—and we must ensure that clinical training seizes this opportunity as well. Currently, the medical school curriculum on ultrasound is sorely lacking”

Understanding that Ultrasound is now a technology that is converging to Mobile is important because this highlights a much more fundamental flaw in current medical education: Medical Schools don’t teach students to use the supercomputers they carry with them 24×7 even though they’re already far more powerful than the £10Million surgical robots teaching hospitals were buying just a decade ago. They don’t examine them on how they use their mobiles. Even the RCGP membership exam still fails a Doctor who has a Mobile on their person (even though they will probably never be a time in their lives when they consult with a Patient and both are not carrying a mobile that’s at least as powerful as the latest iPhone XS).

“While I predict that the physical exam in the inpatient setting will be most subject to technological transformation, even the outpatient annual physical exam demands a culture shift. The annual physical exam costs the healthcare system an estimated $10 billion, and accounts for nearly 10% of visits to primary care doctors—arguably taking away time from more urgent and necessary visits. Moreover, there is no data to suggest that the annual physical has any direct clinical benefit. In theory, it keeps patients more connected with the health system, which is certainly valuable, but one might question if it’s worth the cost mentioned—and if there are better, more targeted ways to do this specifically for high risk patients.

I am increasingly realising that even if I want to spend more time at the patient’s bedside and less time in front of a computer (which trust me, I do), this may not actually be what is clinically best for the patient. Today more than ever before, doctors are bombarded with hundreds of data points that require quick analysis and decisive decision making. We also have far more therapeutic options now than we ever did before. While it’s difficult for me to admit, I may be doing more for my patients by clicking a mouse through a table of numbers, and typing in text orders that will be executed by excellent nurses. With this in mind, I believe it is critical that we train more doctors in the regular use of affordable bedside diagnostics (including but not limited to ultrasound) to create a new standard for the physical exam”

Hear, hear, bring on the Smartphone Medical!

“Ultimately, putting a stethoscope on my patient may be more of a reassurance for them than it is for me, which makes it still worth doing. But going forward, we need to find a new modern standard for the physical exam that physicians will find clinically optimal”

Interesting observation. I think it’s important to remind Doctors that if Patients see them uncomfortable using their mobile (a tool of our time that you’re expected to have mastered) they may doubt how current your medical knowledge is.

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