Is The Physical Exam Obsolete?
By Dr. Farhan Lalani, Assistant Clinical Professor in the Division of Hospital Medicine at UCSF.
For many internists, there is no greater passion than the art of the physical exam. Despite having been in practice for a decade, my chest still billows with pride when I successfully identify shifting dullness in a patient with new abdominal distension. Or, on a recent memorable occasion, when I diagnosed severe anemia based on palmar pallor. In a palpable way, the physical exam connects us with our intellectual forebears. It’s the very same tool that Osler and Hippocrates used to diagnose their patients.
But medicine is changing rapidly. In the last decade, there has been no more important advance in the field of Hospital Medicine than the increasing use of the point-of-care ultrasound (POCUS). It has revolutionized the art of diagnosis and has been particularly astounding to physicians like myself who trained prior to its widespread use. Whereas in my early days in medicine I would have put great care into listening carefully for the faint wisps of pectoriloquy when hunting for lung consolidation, now I’m much more likely to put an ultrasound probe on the patient’s chest. Having tremendous admiration for the physicians who came before me who, over many centuries, perfected the physical exam, there is a part of me that feels as though I’m cheating.
Having made the transition in the last decade from POCUS novice to POCUS teacher, I’m often asked if POCUS is the modern replacement for the physical exam (though, if I’m being honest, I’m more often told that POCUS is the modern replacement for the physical exam). As a teacher of POCUS, I am of the firm belief that there is no skill that an Internist can learn that will improve her diagnostic ability more than POCUS. In the coming decades, POCUS exams will become the standard of care in the workup of several common complaints (i.e. shortness of breath, chest pain, etc). However, in my view, it is most certainly not a replacement for the physical exam. It is, rather, an extension of it (and, if I’m being honest again, it is the most important extension of it).
This is for several reasons. Firstly, the indications for POCUS are more specific. A patient presenting with shortness of breath certainly warrants a POCUS exam, but a patient presenting with cellulitis likely does not. The indications for a physical exam are the presence of a provider and a patient with any complaint. And that’s all. Secondly, there is the possibility of adverse events with the inappropriate use of POCUS. At UCSF, where I help to run the POCUS program, we have strongly encouraged POCUS use only for approved indications and only by experienced providers. Until such time that POCUS is widely used and all hospitalists are very comfortable with its use (as they are with the physical exam), every institution will need to implement safeguards to prevent adverse events. And finally, there are certain diagnoses that can only be made with the physical exam or for which POCUS has low or unproven sensitivity. For example, any pulmonary pathology related to bronchial issues (i.e. COPD/Asthma).
With that said, the use of POCUS as an extension of the physical exam drastically improves diagnostic capability, the overall clinical encounter, and the teaching of medical students and residents. With so many of us being so busy with heavy patient loads, time spent at the bedside is often cut woefully short. POCUS brings us back to the bedside and, not surprisingly, has been shown to improve patient satisfaction. I am routinely in the practice of engaging in codiscovery with my patients. I typically scan with the wireless Vave and allow the patient to hold my tablet while I scan. I explain what I’m looking for and interpret the images I capture in real-time. This gives my patients a front-row seat to the diagnostic process and allows them to be participants in their care in a way that was not possible before.
In addition to this, it is an excellent teaching tool. It was William Osler who said, “Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from the words heard in the lecture room or read from the book. See and then reason and compare and control. But see first.” There is no greater practice that embodies these words than that of the physical exam and POCUS. Not only does it bring us back to the bedside with our learners, but POCUS allows them to literally see pathology. In my experience, learners are very enthusiastic about POCUS and at UCSF the residency POCUS elective has been the most popular elective in the residency program for several years running.
For me, POCUS has played a central role in increasing my provider satisfaction. Similar to my use of the standard physical exam, my chest still billows when finding new hydronephrosis or a large pleural effusion. While this has yet to be demonstrated broadly, I am quite certain that for me POCUS use has meant lower utilization of resources like chest x-rays, CT scans, echocardiograms, etc, and has likely resulted in shorter lengths of stay for many of my patients. My POCUS-enhanced physical exam has improved my diagnostic capability, and there is great satisfaction in getting the diagnosis correct early during the patient encounter and implementing treatment immediately. Learning POCUS is, however, an investment of both time and money. But it is, as I said above, the most practice-changing skill that a Hospitalist can learn and is well worth the investment.
About the Author
Dr. Farhan Lalani, MD
Assistant Clinical Professor, Division of Hospital Medicine, UCSF
Farhan Lalani is an Assistant Clinical Professor in the Division of Hospital Medicine. He is board certified in Resistant Hypertension by the American Society of Hypertension. Prior to coming the UCSF, he worked at Intermountain Healthcare where he worked as a hospitalist and as their lead hypertension specialist. He started and directed their resistant hypertension clinic, participated in writing their system-wide guidelines for hypertension management, and worked to build and implement their population health-based blood pressure management program.
He is also certified in Point-of-Care Ultrasound by the American College of Chest Physicians. At UCSF he is deeply involved in the education of faculty, residents, and medical students in clinical ultrasonography and is the quality assurance lead within the Division of Hospital Medicine. He is an Assistant Clinical Professor of Medicine and is a recipient of the 2019 Academy of Medical Educators Excellence in Teaching Award.