The progression from a second year medical student to a third is one of great anticipation. To a preclinical student, transitioning to the wards signifies a rite of passage and entrance into the professional medical community. As our second year draws to an end, an undercurrent of excitement grows as we begin to have class meetings about third year scheduling and the dreaded Step I.
In preparation for our time on the wards, and to prove that our physical exam skills are up to snuff, University of Michigan students must also pass the M2 Comprehensive Clinical Assessment. Suddenly, the mild mannered women that we once knew as administrators don ear buds and microphones and become the secret service, guardian of 15 minute sessions testing everything from the cardiac exam and mini-mental status exam to history taking and presentation skills. They snap into their microphones, “Red team, GO!” and “Yellow team, we straight? We go in 3 minutes 19 seconds.” They snap at us, “Don't touch that clipboard yet!” “You can't sit in that chair.” “Ok, now you can sit in that chair if you like.”
However, unlike many of the other tests that we're introduced to, we're never given the sensitivity and specificity of the physical exam tests. A few studies have attempted to quantify certain maneuvers, especially in the setting of PM&R and Emergency Medicine, but if these numbers are known, they're not taught.
The joke about American medicine is that we don't know how to examine patients properly anymore. Unlike doctors in developing countries and Britain, we rely more on labs and imaging. As one surgeon said to a third year medical student who suggested pneumonia in her patient after feeling his chest, “Fremitus?! The most important part of the lung exam is the chest xray.”
You can tell that medical schools are desperately trying to turn this trend around. Every week a different professor says emphatically, “Learn to rely on your history and physical! Ninety percent of your diagnosis is in the H&P!” And yes, that may be true, but if you're hoping to cut costs by sending off less needless tests, it's unlikely. In an age of defensive medicine, even if we take to heart the messages from our professors in our preclinical years, by the time we leave the wards, we'll all be ordering tests just to “make sure.”
However, in the discussion over the importance of the physical exam, debate that seems just as much cultural as it is evidence based, what's overlooked is that no matter how medically important we decide the physical exam is, it also plays an important role in our relationships with our patients. I think there's something innate to humans that responds to a caring physical touch. Though it's not always appropriate to hug or hold our patients' hands, the physical exam gives us a way to physically connect with our patients. Whether it's palpating or percussing, it's a chance to express our compassion for our patient; something that is as important for our patient's trust as it is for our own fulfillment. Ultimately, it's a chance for the patient and the doctor to remember that we're both human; our own little version of the “healing touch.”