Physical examination in the care of medical inpatients: an observational study

doi:10.1016/S0140-6736(03)14464-9

The Lancet

Volume 362, Issue 9390, 4 October 2003, Pages 1100-1105

https://doi.org/10.1016/S0140-6736(03)14464-9 Get rights and content

Summary

Background

Little is known about the clinical importance of skilled physical examination in the care of patients in hospital.

Methods

Hospital records of a systematic consecutive sample of patients admitted to a general medical inpatient service were reviewed retrospectively to determine whether physical findings by the attending physician led to important changes in clinical management. Patients with pivotal physical findings were defined by an outcomes adjudication panel as those whose diagnosis and treatment in hospital changed substantially as a result of the attending physician's physical examination. Pivotal findings were classed as validated if the resulting treatment change involved the active collaboration of a consulting specialist. Findings were classed as discoverable if subsequent diagnostic testing (other than physical examination) would probably have led to the correct diagnosis. Class 1 findings were those deemed validated but not discoverable.

Findings

Among 100 patients, 26 had pivotal physical findings (26%; 95% CI 18–36). 15 of these (58%; 95% CI 37–77) were validated (13 with urgent surgical or other invasive procedures) and 14 were discoverable (54%; 95% CI 33–73). Seven patients had class 1 findings (7%; 95% CI 3–14).

Interpretation

Physical examination can have a substantial effect on the care of medical inpatients. If replicated in other settings, these findings might have important implications for medical educators and quality improvement initiatives.

Introduction

Concerns about physicians' declining bedside skills have prompted the US National Board of Medical Examiners to propose that, beginning in 2004, physicians-in-training must demonstrate competence in physical examination before they can receive a medical licence. Currently, only about a quarter of US medical schools require their students to pass such tests as a condition of graduation.

However, even if all physicians acquire basic skills in physical examination, will they maintain and improve those skills throughout their professional careers? Very few residency programmes include physical diagnosis in their curricula.1, 2 Specialty board-certification examinations no longer require an oral component with demonstration of bedside skills. Continuing medical education conferences rarely offer opportunities to update skills in hands-on examination. Indeed, the time pressures of modern practice, combined with advances in diagnostic technology, seem to undermine the value of these skills. Is expertise in physical examination still important in clinical medicine?

This question is reminiscent of scepticism in the 1980s about the importance of the autopsy. At that time, declining hospital autopsy rates prompted Goldman and colleagues3, 4 to compare the value of autopsies in periods before and after the availability of new diagnostic imaging technologies. These investigators found that the autopsy's yield remained substantial (major diagnoses unsuspected pre-mortem in 22–25% of patients), undiminished from 1959 through 1985. Their findings energised efforts to revive the autopsy as an essential quality improvement process in hospitals.

Thus, it seems noteworthy that no previously published studies have addressed the clinical importance of physical examination in the care of patients in hospital.

Section snippets

Background

In the week after completing a rotation as an attending physician in a hospital, this author began teaching an introductory physical diagnosis course to second-year medical students. In response to students' questions about the importance of physical examination in the care of inpatients, I searched PubMed for English-language medical published work from 1966 through 2001. Finding no data directly relevant to this question, I reviewed the medical charts of all patients who had been admitted to

Results

100 patients were admitted to my service during the 28-day period. Patients' mean age was 55 years; their median hospital length of stay was 3 days. Patients' principal final diagnoses are listed in table 1. Six patients died in hospital. For 28 patients, various language barriers affected my initial clinical assessment.

Chart review identified 37 patients with possible pivotal findings. The adjudication panel rejected 11 of these because they did not meet all the criteria; the remaining 26

Discussion

These results show that physical examination can have a substantial effect on the care of medical inpatients. About one in every four (26%) patients in the present investigation had pivotal physical findings. In many patients, these findings prompted active collaboration by specialist consultants to perform urgent surgical (or other invasive) procedures. The seven patients with class 1 findings were especially important because diagnostic testing other than physical examination would probably

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: The authors developed a clinical examination assessment using volunteer patients and direct observation. Trained faculty preceptors rated resident performance in 7 domains: 1) physical examination technique, 2) identification of physical signs, 3) clinical communication, 4) differential diagnosis, 5) clinical judgment, 6) managing patient concerns, and 7) maintaining patient welfare. The Pearson correlation coefficient was used to determine relationships between performance in each of these domains. Data on residents’ self-assessed competency in the physical examination and perceptions of feedback received during the assessment were collected.
: From December 2018 to February 2020, 113 interns from 2 internal medicine residency programs participated in the assessment. Physical examination technique was significantly correlated with accurate identification of physical signs, differential diagnosis and clinical judgment. Time spent in graduate medical education was negatively correlated with performance. Interns more highly rated the feedback received from this assessment than traditional clinical skills feedback.
: Our findings emphasize the necessity of multi-dimensional physical examination assessment. Observed deterioration of physical examination skill during internship may reflect contemporary practice patterns, which deprioritize the physical examination. Future research on physical examination education should focus on the interface between physical examination technique and related clinical skills.
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Our results demonstrate that the IRO/shift-test is a reliable and valid tool for assessing superior rotator cuff pathology. With good-to-excellent intrarater and inter-rater reliability and strong sensitivity and specificity this test should be considered a valuable addition to clinicians’ cadre of clinical evaluation tools.
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Physical examination still has a role in medical practice even in 2020. Although it is well known that the accuracy of diagnoses are doubled when clinicians examine patients rather than just hear their histories,25 it is not unreasonable to hypothesize that the therapeutic alliance formed between patient and physician when face to face26 is much stronger than when those visits are merely virtual. As pointed out by Chwistek, “There is no doubt that the virtual visit is a fundamental alteration to the patient-physician encounter…an imposed order commands the in-person visit, and it travels beyond the verbal: body language, rush of emotions, physical proximity, and touch.
COVID-19 and our public health responses to the pandemic may have far-reaching implications for cardiovascular (CV) risk, affecting the general population and not only survivors of COVID-19. In this narrative review, we discuss how the pandemic may affect general CV risk for years to come and explore the mitigating potential of telehealth interventions. From a health care perspective, the shift away from in-person office visits may have led many to defer routine risk- factor management and may have had unforeseen effects on continuity of care and adherence. Fear of COVID-19 has led some patients to forego care for acute CV events. Curtailment of routine outpatient laboratory testing has likely delayed intensification of risk-factor–modifying medical therapy, and drug shortages and misinformation may have negative impacts on adherence to antihypertensive, glucose-lowering, and lipid-lowering agents. From a societal perspective, the unprecedented curtailment of social and economic activities has led to loss of income, unemployment, social isolation, decreased physical activity, and increased frequency of depression and anxiety, all of which are known to be associated with worse CV risk-factor control and outcomes. We must embrace and evaluate measures to mitigate these potential harms to avoid an epidemic of CV morbidity and mortality in the coming years that could dwarf the initial health effects of COVID-19.
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ArticlesPhysical examination in the care of medical inpatients: an observational study

Summary

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Background

Results

Discussion

Am J Med

Am J Med

Jt Comm J Qual Improv

Creation and assessment of a structured review course in physical diagnosis for medical residents

J Gen Intern Med

An advanced physical diagnosis course for internal medicine residents

Acad Med

The value of the autopsy in three medical eras

N Engl J Med

Diagnostic yield of the autopsy in a university hospital and a community hospital

N Engl J Med

The lasting value of clinical skills

JAMA

Physical examination: frequently observed errors

JAMA

Assessment of clinical skills of residents utilizing standardized patients

Ann Intern Med

Assessing housestaff diagnostic skills using a cardiology patient simulator

Ann Intern Med

Assessment of basic physical examination skills of internal medicine residents

Acad Med

Detection and correction of house staff error in physical diagnosis

JAMA

How well do internal medicine faculty members evaluate the clinical skills of residents?

Ann Intern Med

The rational clinial examination. A primer on the precision and accuracy of the clinical examination

JAMA

The clinical examination. An agenda to make it more rational

JAMA

Articles
Physical examination in the care of medical inpatients: an observational study