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The "why I dislike the physical exam" thread

Discussion in 'Pathology' started by yaah, Apr 18, 2004.

  1. yaah

    yaah Boring
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    [pessimism]
    I think the physical exam needs its own thread, because simply I am tired of it. It doesn't do what it needs to do, and everything that is found is so subjective and nonspecific that it might be better off if it was eliminated. Near as I can tell, the only purpose the physical exam serves is to reassure the patient that the physician or student is carefully paying attention to their physical state and assessing the need for treatment.

    I must admit that certain aspects of the physical exam are important. The vital signs are key. But these can be done by a machine or a nurse and most physicians don't do them anyway. Examining the skin is also important, but at the same time describing findings is so difficult that unless you are the one deciding on the treatment, it is basically not helpful to do.

    Listening to the lungs? Fine, go ahead, but if the patient is short of breath they are going to get an xray or cat scan anyway. Heart? Sure, but if they have a fever, they generally get blood cultures and if it persists they get an echo regardless of murmur. Abdominal? Useless except to find an acute abdomen, and even then it isn't that helpful. Neuro exam? Listen to the patient, they'll tell you what your findings are going to be. You say your arm is weak? Wow, my physical exam suggests that as well!

    I shouldn't be so anti-physical exam. After all, it is important for doctors to be able to correlate patient complaints and symptoms with a unifying diagnosis. But labs and films always seem to help more. Sometimes people will say, "that's a classic physical exam finding" but yet they always have to confirm it with a film or a test, because it's not specific. And if a lab test or a film keeps telling you something isn't there, but the physical exam keeps telling you something might be, which one do you trust?

    I know, I know, people are going to come up with ways in which the physical exam is vitally important, and it is irresponsible of me to think like this. So be it. A good history is much more important in almost every situation. Some diagnoses can't be made without a good physical exam, I know. But most of these (otitis media, pharyngitis) are visual or the history is even more effective.

    Plus, I think the physical exam is a large reason why so many hospitalized patients end up with MRSA or VRE colonization. Too many doctors who want to feel their belly.

    I still have 2 weeks of ID and 4 weeks of neurology left. Many more days of the stethoscope, reflex hammer, blah blah blah. I've learned what I can. Get me to residency.

    R.I.P. Physical Exam. We knew ye well. But ye be outdated and other modalities be more helpful. Besides, as pathologists, we don't really care about you.
    [/pessimism]
     
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  3. yaah

    yaah Boring
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    So, with all of the nice posts we have today, no one else wants to complain about the physical exam? Maybe I am the only one. We had a nice one today. Consulted for "groin infection." That's always a good sign. The physical exam sure is important on that one! Better listen to the lungs! I'll take the ER's word on this one. Culture the abscess.

    Oh well. Continue to enjoy your physical exams.
     
  4. Weil-Felix

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    Um, I just don't like touching people. Is that wrong of me? I guess it's fortunate that I am going into path, huh?
     
  5. Weil-Felix

    Weil-Felix Super Flying Squirrel
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    Oh, yeah...and also....I hate physical exams, not because I'm bad at them, but because NOBODY BELIEVES ME ANYWAY! There have been a couple of times when I heard a murmur, loud and clear (+3/6) that even the cardio fellow neglected to take note of. I write it every day in my note. But does anyone even acknowlege it? No! They don't give a rat's ass because I'm just a stupid medical student, so what do I know? (Don't mind my pessimism. I'm just ready to finally graduate and get a little "R-e-s-p-e-c-t, find out what it means to me....")
     
  6. Brian Pavlovitz

    Brian Pavlovitz give me that marrow!
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    Karma points for the Aretha Franklin reference!! :laugh:

    I'm with you guys on P.D. In fact, this Friday I have to take our clinical skills "final". I'm trembling with anticipation!!

    You know, I really don't mind touching people...I just want them all to be clean. Is that wrong?? :D "...hold on a second, Mr. Smith; let me douse you in clorox before we begin..."
     
  7. yaah

    yaah Boring
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    Nobody believes me either. On OB, we had a lady a couple of days post partum who was febrile and they were convinced it had nothing to do with her C-section incision, despite me, on my exam, determining that she was very tender around the incision, which was erythematous, indurated, and quite possibly sitting over fluctuance. I touched it, she yelped. The resident said, "ok, ok, we want to repeat a pelvic exam to see if she might have endometritis." 5 hours later, attending shows up, talks to the patient, feels her belly, says to the resident, "Did you examine this patient? She has an abscess under this incision." Resident: "Um, yeah, I guess we didn't think it was that serious."

    Yaah rolls his eyes and crosses off OB on the list of potential careers.
     
  8. Stinger86

    Stinger86 Intern year? Ha!
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    I just took our clinical skills final as well, which was super stupid, because there were things on the checklist that no doctor in his right mind would do to the patient, when the history made the diagnosis so obvious.

    The old axiom, "listen to the patient, they'll tell you everything you need to know" is probably the most important thing I've learned in medical school so far. The only cool thing about the PE is when you pick up a heart murmur. Everything else can be told to you by the patient.
     
  9. yaah

    yaah Boring
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    Hey Brian P and Stinger, you guys related? Your pictures look kind of similar! I guess the real question is, who can bench press more? (That is what the little cherub is doing in those avatars, right?)

    By the way, Brian. Don't forget to wash your hands while in the room with the patient (preferably before you start the PE!). Here they dock us significant points for not doing this. And word is, on the new clinical skills part of USMLE II you will fail (insert dramatic music here) if you neglect to wash your hands.
     
  10. Brian Pavlovitz

    Brian Pavlovitz give me that marrow!
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    I noticed that, too (in reference to our avatars). I thought the little cherub was doing chin-ups, though. As for how much I can bench press, I would make a bet that Stinger would beat me hands down! Especially since being down here, my arm muscles have atrophied (not that they were large to begin with, either).

    Thanks for the advice--you can bet my hands will be washed thoroughly. I've heard horror stories about people failing the CSA because they didn't wash their hands first. Yikes!
     
  11. yaah

    yaah Boring
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    Hmm...This makes me wonder if the "credit for washing of the hands" points could still be collected if you did a crappy job. Do they grade you on technique? 10 seconds, scrub with soap, turn off faucets with paper towel, etc. Can you just dunk your hands under the faucet like so many people do and let the water run off? I am SO glad I don't have to take the CSA, and I don't mean to rub it in to anyone who has to do it. I feel for you. As Bill Clinton would say, I feel your pain. I will say a prayer to Sir William Osler for you all.

    Great physical exam thing I noticed today. Resident has a patient with a HR consistently above 120 due to sepsis. Every day, physical exam for the heart reads "RRR nl s1 s2 no m/r/g." Well, if it's tachycardic but regular, it's not RRR. Even a pathologist knows that! And why is it that everyone checks for and reports "EOMI" and "PERRLA"???? Are these really vital things to do in someone with abdominal pain? Did they have a stroke? Did you really check the "A" part of the PERRLA? A patient admitted for pneumonia will have all these stupid things listed like "PERRLA" as if the exam was so exquisitely done. But the lung exam will say simply "decreased breath sounds L base." Dullness? Egophany? Rales? Oh, I get it, you saw the chest xray and it said "Left pleural effusion!" If I was a medicine attending I would be such a pain in the butt to work for. I'm too anal. On a sedated patient, you can't reliably say their abdomen is non-tender or there is no calf tenderness, yet people do it all the time.

    I shouldn't complain so much since i hate the physical exam.
     
  12. Stinger86

    Stinger86 Intern year? Ha!
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    I actually picked my avatar because he 1) looks like a troublemaker and 2) dresses like a bumblebee. But come to think of it, the name stinger as I conceived it has absolutely nothing to do with any kind of obnoxious insect, so I'm probably going to change it. Maybe I'll take on the Beethoven avatar (regardless of the first three letters), and challenge yaah to an e-benching contest, and ultimately reign supreme over avatardom.


    That sucks about failing the CSA if you don't wash your hands. I missed a point on my last clinical exam because I washed before the Male Genital Exam, but failed to wash again AFTER the exam, even though I had to wear these massive latex gloves. There needs to be a GEA, genital exam assistant, who shows up and does every single awkward physical exam for you, and then reports the findings afterward. Wow, I really don't like fiddling with genitalia in a medical setting. :eek:
     
  13. yaah

    yaah Boring
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    I'll tell you whut, that GEA idea is quite possibly one of the most brilliant ideas I have heard of. Can you imagine someone hiring a personal GEA to follow them around and perform the nether region exams on all of their patients. This is Bill, he will be examining your testicles today. No, he doesn't need gloves, he's a professional and he's seen and touched it all. Sometimes, on the gyn-onc service, I felt like a GEA for the gyn-onc attendings. They would take me into the room and make me do the exam while they reminisced with the patient about old tumors, incisions, and chemotherapy. After that experience, I believe a GEA should be highly compensated, although I am quite sure that one could find people out there who would do it for free. These are probably also the same people who find themselves attracted by watching someone else urinate.

    I'll also tell you whut, that quote of yours, "Wow, I really don't like fiddling with genitalia in a medical setting," is freaking hi-larious. That's the kind of quote that would get you at least 5-6 replies of simply :laugh: :laugh: or :eek: :eek: in other forums.

    About the avatars, Beethoven has a rather stern look on his face, fiery, etc. I like that picture. Of course you may also use it, but instead of a benching contest we would probably have to have a Beethoven knowledge test.
     
  14. cookypuss3

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    As a lucky bastard who gets to graduate in 2005 from a ridiculous D.O. program, I will have the honor of being one of the first guinea pigs to go through the COMLEX Part II Physical Exam. Please note that it is offered in ONE location in the country, and that would be Philly. Also note that the exam fee is $1000. Calculate how much it will cost to fly from Phoenix to Philly and stay in some crap hotel for 2 nights. Add that all up. I can feel my blood pressure rising just thinking about this (and that's a damn important vital sign change to note, right?). I can't wait to throw my stupid stethoscope in the back of a junk drawer somewhere when this is all over. God bless pathology.

    As for diddling people's genitalia, it's really not all bad when done outside the workplace.
     
  15. yaah

    yaah Boring
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    Well said, cookypuss. Do you think anyone else has ever said, "well said, cookypuss" before? Sounds funny. Kind of like seeing a really beautiful model and finding out her name is Bertha. No offense to all the Berthas out there, it's just not a very pretty name.

    I know, I think the worst part about all these stupid CSA tests is that they are not offered in many places. The Step II part I think will be offered in a few more places than just Philly, but not many. I would have had to go to Philly too, probably at the same time as a bunch of New Yorkers which would have been unpleasant. No offense to New Yorkers. I'm sure many of you are nice, I just have only met a couple of nice ones. And charging $1000 is simply wrong. Although I guess they have to pay the poor individuals who portray the patients quite a bit of money to put up with all of us schlubs.

    I was thinking of destroying my stethoscope.
     
  16. cookypuss3

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    Dammit!!! I hadn't even considered all the New Yorkers. Thanks oodles there, yaah.

    As for paying the "actors" who portray our suffering patients - that should be like required community service for DUI convicts or bad check writers or something. $1000 is completely and totally absurd. It's just a money making machine for the testing company.
     
  17. yaah

    yaah Boring
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    Schadenfreude, my friend. A word to live by. These people love inflicting misery. Want to be a doctor? OK, you have to do well in college and take all these extra classes. Then, you have to take this other test to prove you have learned a lot from these extra classes. And then, you have to be accepted. So, after paying $$$$$ for college you move onto med school where you have 4 more years of education at excess $$$$$, all the time taking more and more tests. So, just to be nice, lets make everyone pay another $1000, plus travel expenses, and force them to travel to a city that everyone loves to dump on (Philly) and interact with actors. After all this, if you forget to freaking wash your hands, sorry, you can't be a doctor just yet. Just laugh about it all, you'll get through it. Schadenfreude.

    If, when you get to the testing center, there are pens or pencils, or anything else that you can "accidently" take with you, do it.
     
  18. cookypuss3

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    Dem dere are words to live by. I'll make sure I have pants with big ol' pockets. Hopefully there's lots of donuts too, and extra napkins so I can wrap them up before I stick them in dry-clean-only pants.

    And I'm so glad someone else understands schadenfreude. Sigh.
     
  19. Nilf

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    I've heard that there is a 15% or so LIFETIME failure rate on COMLEX Part II Physical Exam (a buddy of mine told me) . I don't know where this number comes from since this is a new exam, I reckon.

    By the way, what's up with all the German connections on this forum? Are most of pathologists germanophiles? (I spend a year in Heidelberg)
     
  20. yaah

    yaah Boring
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    Well, I believe Virchow was german. I don't know, I just think german is an interesting language. I like how you can keep adding things in to make a word longer and longer, modifying the original. Plus, sometimes it is just downright funny. Unterseeboot means submarine. :laugh: Someday I will learn german, as I said though, not yet. Other languages just don't have the cache. I have fun sometimes by going to german webpages and having google translate them for me. Hi-larious. Plus, german culture can also be funny, all this studded leather and technorock.
     
  21. MirkoCrocop

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    lol. i was reading through old threads (looking for advice on what the heck to read before residency) and found this thread.

    little bump for never doing a physical exam again! grats to everyone starting june/july
     
  22. Path or bust

    Path or bust I like meat
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    One of the reasons that helped decide on pathology was the fact that alot of the residents & attendings shared many of my thoughts on medicine. I cannot emphasize enough my agreement with yaah regarding the physical exam. I am glad I can put most of it behind me and move on to greener pastures. :D
     
  23. Tiki

    Tiki Girl named after a Giant
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    I hated the physical exam because I could never feel what they said I should feel.

    Attending: Oh, med student Tiki, feel this so very very very very very enlarged spleen on Mrs. Splenomegaly.

    Assorted other medical students: Oh yeah, we feel it! It is soooo obvious.

    Tiki: (jabbing the poor patient's belly and not feeling a damn thing) Uh, yeah. I think I feel it. (Even though it just felt like every other abdomen.)

    And the worse was the OB exam, when the residents would say, "Feel those ovaries, Tiki?" I never once felt anyone's ovaries. I have short fingers, and therefore should not have been the one to ever do manual exams.

    Anyway, I too, have chucked my stethoscope into the nether-regions of my closet, hopefully never to be seen again.
     
    #22 Tiki, Jun 4, 2008
    Last edited: Jun 4, 2008
  24. Path or bust

    Path or bust I like meat
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    I honestly don't know where the hell my stethoscope is. I lost it sometime during my 4th year. On my geriatrics rotation I had to continually borrow from nurses and would always get the crooked eye.
     
  25. gbwillner

    gbwillner Pastafarian
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    Youz guyz are on crack. The physical exam is an excellent way to make initial diagnoses with a good Hx.

    I agree that simply listening to the patient's heart and lungs when they complain of a cold is simply to reassure the patient (and are the least important tests in healthy patients), but a focused exam is, secondary to the Hx, the most important thing you can do.

    SOme of you guys are probably so far removed from it that you just don't remember all the uses. I'll give you a few examples:

    1. Pt comes in complaining about 3 weeks of fatigue. On exam you note petichiae on the lower extremities and several enlarged lymph nodes. Do you mean to tell me you need a CBC to tell you there is a problem here?

    2. Pt comes in with a sore throat and fatigue. On exam you see white plaques on the patient's erythematous tonsils. You also notice an enlarged spleen and palor. Was the PE useless here?

    I know you said that people will come up with examples- that's because the PE is critical in making a Dx.
     
  26. docbiohazard

    docbiohazard Highly ranked amateur
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    I remember constantly being lectured "90% of diagnosis can be made on history and physical..." as a future pathologist, I always joked that I couldn't wait until I got to lecture medical students so I could tell them "Many people have told you that you can diagnose on history and physical alone... those people are trying to get you sued! What you need is cold, hard, irrefutable clinical data! Order those tests!! The more the better!!" Just to do my part to increase billing for future pathologists... :)

    DBH
     
  27. Ziehl-Neelsen

    Ziehl-Neelsen I'm perfectly calm, dude.
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    Virchow was German (a Berliner actually) and a strident anti-Catholic. I was tooling around the former East Berlin a few years ago and saw that one of the campuses of Charite Hospital (Europe's largest university medical center) is named for Virchow. I decided to check it out and discovered it was the campus at which he taught and performed most of his research. There is now a giant statue of Virchow out front.
     
  28. Path or bust

    Path or bust I like meat
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    The physical exam is a good start but it's not really diagnostic of anything. An H&P is always followed up or verified with laboratory or imaging, which is what I believe is critical in dx. The differential dx on each of your examples is huge and you almost always follow each one with many tests. Even step 2 CS emphasizes this: after a H&P, we give 5 ddx and 5 tests.

    I agree that with a good H&P you should have a good idea of the dx but unfortunately that is not how our system works. I think the legal system has alot to do with it --> increases costs exponentially.
     
  29. Cloaca

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    Best reason EVER for doing a physical exam:

    As a med student I had an elderly patient in the ER who was brought in by her family (with whom she lived) because she had developed a small rash on her left arm and generally wasn't feeling well. But she was otherwise "ok" according to them and to her. We put her on one of the cots, drew labs, etc - resident takes off, telling me to examine her. I tried to get her to sit up to listen to her lungs and in doing so touched her back and Mother of GOD this woman has something huge and fluctuant back there. I pull up her shirt and HOLY MOTHER OF GOD her ENTIRE back is ONE BIG ABSCESS. At the same time, her labs came back and she was in multiorgan failure from sepsis. Neither she (??) nor her family knew about it. We drained out, like, 2 L of abscess fluid. Ugh.

    So physical exam can uncover things patients don't tell you about.
     
  30. MirkoCrocop

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    hey guys quit crying! :scared:

    this whole thread is meant to be taken with a grain of salt/sense of humor/sense of sarcasm.

    i think we'd all agree there are obvious uses to the physical exam...
     
  31. Strength&Speed

    Strength&Speed Need more speed......
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  32. Strength&Speed

    Strength&Speed Need more speed......
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    i personally like "burgermeister" for i believe...mayor

    also...chuck knoblauch is cool because knoblauch means cabbage
     
  33. Napoleon1801

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    I agree with you sentiment, especially upon the idea of "classical signs," especially when said sign only has a 50% sens and specificity. I should go flip a coin, I think it would be more scientifically accurate sometimes....


    Oh yeah, here's my German contribution: http://schokolade.ytmnd.com/
     
  34. yaah

    yaah Boring
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    Of course physical exams can be worthwhile and provide good clinical information, they make the diagnosis in many cases. The entire specialty of neurology is based on performing an appropriate physical exam.

    But these points do not mean that 1) I have to like it; and 2) most of the "physical exams" performed in a hospital setting are worthless.
     
  35. Matte Kudesai

    Matte Kudesai Senior Member
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    The DRE has to be the crappiest...:laugh:
     
  36. Strength&Speed

    Strength&Speed Need more speed......
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    I think its funny when people reference the Old Greats of Medicine. I bet half of these dudes would come back and take a steaming dump on the miscreation we call medicine. Virchow would come back and say "Schiesse!!! I get an MBA!"
     

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