Opinion/editorial: The vanishing physical exam - Things we forgot from medical school

Tuesday, May 01, 2018 12:23 PM

by Robert N. Alsever, MD, FACP, FACE, and Carl E. Bartecchi, MD, MACP

Editor’s note: Colorado Medicine occasionally accepts and publishes opinion/editorial columns on topics of interest to Colorado physicians and consistent with topics associated with the Colorado Medical Society operational plan. The opinions expressed in all guest opinion/editorials are those of the author and do not necessarily reflect the views of the Colorado Medical Society.

The stethoscope – commonly seen wrapped around the neck of a physician but now also a nurse, nurse-practitioner, physician assistant, paramedic, emergency medical technician and others – has become the sign of a professional health care provider. It gives credibility by suggesting the person wearing it has special skills to use the diagnostic findings it reveals.

Though the potential to detect useful information – heart valve problems, heart failure, heart rhythm problems, partially occluded blood vessels, pneumonias, lung fluid accumulations, asthma, emphysema and so much more – is there, its effective use and interpretation requires plenty of expert training and knowledge of anatomy and heart and lung pathology.

Before the $300 chest x-ray, the $4,000 CT scan and ECHO, sometimes all a diagnosis requires is a good stethoscope; a careful, well-trained listener; and proper application of the stethoscope to the skin over the part of the body under surveillance. We emphasize SKIN because more and more in the media, in doctors’ offices and in other health care settings we see the improper use of this valuable tool while examining a patient: stethoscopes placed over shirts, blouses, pants, paper drapes and even sweaters. This greatly diminishes the possibility of detecting the sometimes soft or difficult-to-hear sounds that point to the pathologic processes suggested above. The medical literature is replete with guides telling us that the stethoscope should be placed directly on the patient’s skin so as to avoid the distortions caused by clothing – something that we were all taught in medical school. They might as well be examining a shirt and deducing the patient’s problems using the information from the “shirt” exam.

It is true that the stethoscope has declined some in its use and popularity due to the availability of high-tech diagnostic imaging techniques such as echocardiograms and pocket-sized ultrasound devices, which can provide more detailed information. However, there is a place for the use of the stethoscope to rapidly detect and diagnose, in the heart, lungs and bowels, important auscultatory changes that can lead to rapid and effective treatments before scheduling the high-tech, high-priced, high radiation exposure CT scan. This is especially true when more sophisticated imaging tests are not easily accessible.

Failure to take the time to adequately employ the use of the stethoscope has been blamed on practice patterns that has been excused by overworked physicians and nurses with production goals that don’t allow for necessary patient evaluation because of the burdensome and arguably useless electronic medical record. It pushes physicians away from examination of the patient and toward testing that patient. It is important that we address these barriers to physical examination, a key low-cost and efficient part of the patient evaluation.

Among the things ignored from training or forgotten from our medical school years is the use of stethoscope – a tool that shortens the physical space between the examiner and the patient. It is part of the skill set that makes you a real doctor. A Harvard medical school professor, Elazer Edelman, MD, PhD, summed it up by pointing out that the stethoscope exam is an opportunity to create a bond between the doctor and the patient: “You can’t trust someone who won’t touch you.”