Physical Exams: Where’s the Beef?

“At present, 2 trends in teaching clinical medicine seem destined for harmonious marriage or perhaps mutually assured destruction: a renewed interest in physical examination and the push to provide high-value, cost-conscious care.”¹

The recent flurry about the pros and cons of physical examinations has been informed by another timely publication.¹ The authors make some critical points that should be considered in the current debate.

First, they say, “physical examination might represent waste when applied without context.”

That is exactly why the physical exam has lost traction as the “yearly physical,” which definitely lacks context.

Second, “we need to shift our emphasis . . . [and ask for] more robust evidence basis.”

The authors decry the sparse evidence-based data regarding the physical exam. They ask for larger prospective studies, and I say here, here! How much of what we do on physical exam is valuable and how much is waste?

Enter a new approach: the Evidence-Based Physical Examination. Have you heard of JAMA’s “Rational Clinical Examination Series”?² Let me summarize two publications in the series that get at evidence-based examinations.

Twenty-eight studies assessed examinations for shoulder pain.³ Only 5 of those 28 received adequate Quality Scores. A painful positive arc test and positive external rotation resistance test were the most accurate for detecting rotator cuff disease.

What did I learn from this paper? We need more evidence-based physical examination studies that are well designed. Many do not warrant serious review. There is waste in our exams. Of the many maneuvers clinicians do for shoulders, a substantial portion has zero data to support value. Only those that have scientific merit should be used.

The second study addressed physical examination for aortic regurgitation (AR).⁴ Although cardiologists were good at physical exam for AR, little was known about skill in non-cardiologist clinicians. How do we transfer cardiology skills to others?

To answer the questions regarding focused physical examination and value, we have to have more and better data. We have slighted the valuable efforts of the JAMA series, the CARE Group (Clinical Assessment of the Reliability of the Examination), and texts such as Evidence-Based Physical Diagnosis.⁵ It is high time we neither “praise nor bury” the physical examination, but rather determine its scientific efficacy in specific contexts.

References:

1. Bergl P, Farnan JM, Chan E. Moving toward cost-effectiveness in physical examination. Am J Med. 2015;128:2014-2015.

2. The Rational Clinical Examination. JAMA. August 6, 2014.

3. Hermans J, Luime JJ, Meuffels DE, et al. Does this patient with shoulder pain have rotator cuff disease? JAMA. 2013;310:837-847.   

4. Choudry NK, Etchells EE. Does this patient have aortic regurgitation? JAMA. 1999;281:2231-2238. 

5. McGee S. Evidence-Based Physical Diagnosis. Philadelphia: WB Saunders Co; 2001.