In the era of laboratory testing and imaging reliance, the physical examination is often neglected. And, indeed, for many suspected diagnoses, the physical examination adds little – the positive or negative likelihood ratios associated with specific findings are not sufficient for ruling-in or ruling-out disease.
However, as this study describes, there is at least occasional value in performing a physical examination. This is simply an e-mailed survey to five thousand clinicians asking for a vignette regarding a delay in diagnosis relating to a missed physical examination finding. There were 208 responses to the survey meeting inclusion criteria, and, in general, the joy in this article is in the Supplementary Table 1, which includes such gems as:
- Missed pregnancy with twins before hysterectomy
- Missed clavicle fracture, labeled “rule out myocardial infarction”
- Missed previous appendectomy scar and made diagnosis of appendicitis again
- Missed giant ovarian cyst, labeled as ascites
- Missed gunshot entrance wound in emergency room
This general canvassing survey provides no information regarding the frequency of such misses, and some of the other 208 responses are not quite as straightforward. The authors do subjectively note a pattern to some of the responses and suggest:
- Acutely ill or painful patients should be fully exposed
- Genital and rectal exams should not be omitted when relevant
- Don’t forget shingles
They also note the physical examination is a “low-cost procedure”, which is, in part, true. It is certainly less expensive than most laboratory or imaging procedures. The scope of the exam dictates a time-cost of a limited physician resource, however, and even a couple extra minutes per patient could result in dramatic decreases in efficiency. The authors here, while focusing on the “misses”, do not mention the possibility of false-positive findings potentially noticed on a less-focused examination, and the potential downstream resource costs associated with investigation of normal variants.
Future research could provide a better accounting of the true incidence of preventable diagnostic error associated with physical examination deficiencies – and the complex factors predicting the appropriate scope of examination in different settings.
“Inadequacies of Physical Examination as a Cause of Medical Errors and Adverse Events: A Collection of Vignettes”
Unfortunately, in this era of patient satisfaction scores, there may be some value to examining the patient just so the patient feels they've been examined. I'm sure we've all experienced the patient who comes into the ED saying they went to some other doctor or hospital and that "they didn't even examine me".
Palpation of abdomen. Mic drop.
Palpation of abdomen. Mic drop.
I find the evidentiary approach to physical examination to be (in most cases) misguided, as it falls into the same trap as many attempts to study diagnostic modalities — that of reducing the entire diagnosis to a single factor and then becoming perplexed when its predictive value is poor. A CT scan may make the diagnosis based upon a single datapoint; the physical exam uses a broad constellation of positive and negative findings along a spectrum, and that's a difficult thing to study, especially when every one of them is usually rather clinician-dependent (no, not the same as imaginary!).