Physical examination in patient-centred care

Dear Colleagues,

A body of literature is questioning the value of the so-called annual physical¹—so much so, that it is no longer funded in several provincial and territorial jurisdictions. We are now talking about a more focused examination, targeted to specific age-related risk factors, or an examination similar to the annual physical but performed less frequently.^2,3 What is the role of the physical examination (PE) in the context of a patient encounter regarding a problem requiring further evaluation? Is the stethoscope really passé in the evaluation of cardiac complaints?⁴ Should we really ditch the PE in this context because the guidelines do not include any information about its value?

The bedside ultrasound as a point-of-care testing device is often mentioned in these discussions as replacing the stethoscope, which has been an enduring tool for evaluating cardiac concerns for 203 years. Mention is made of the enhanced information bedside ultrasound can provide in imaging and function, the portability of the information across practice settings (eg, from the emergency department to the operating room), and the perception of enhanced objectivity.⁴ This is in the context of recent studies showing that the ability of physicians to make a clinical cardiac diagnosis is very limited, in the range of 20% to 40%.^4,5

Those concerned about the technological trend replacing the primacy of the PE offer differing views, starting with the concept that the value of the PE goes well beyond its diagnostic usefulness.⁶ There is a great deal of uncertainty in medicine. A complaint such as “left shoulder pain” could be musculoskeletal in origin but could also be referred pain from any of various sources. What type of and how many point-of-care tools will we need if we do not begin with a good history and an appropriate PE? Recent breast screening guidelines do not recommend self- or clinician breast examination.⁷ Yet, a 2016 Quebec study shows that 5% of breast cancer lesions are missed with mammography and ultrasound and can only be detected by examination.⁸ In a recent CFPC presentation about virtual care and telemedicine, participants were reminded that “a major challenge to virtual care is the overcoming of scope of practice limitations that are caused by the inability to perform most PE maneuvers.”⁹

The burgeoning of clinical practice guidelines and initiatives such as Choosing Wisely are bringing renewed interest in these discussions; however, these conversations are not new. Think of the introduction of obstetric forceps for obstructed labour in the 1730s or the advent of the incubator for premature newborns at the beginning of the 20th century—each innovation with its share of opponents. My hope for the future, as these conversations mature, is that we will avoid looking at this in a binary, “either-or” manner. This is not about the primacy of technology versus the PE, but more about the humans who use these tools, in the context of producing and nurturing caring, compassionate, person-centred clinicians. There are important implications for undergraduate and postgraduate education and for continuing professional development. We also need to create and support a robust research agenda that includes comparison of PE with medical devices, the results of assessments with and without PE, and the engagement of Canadians. As we move forward we will need the courage to question ourselves and be prepared to make bold decisions regarding the current and future education of physicians in terms of situational awareness and metacognitive skills to facilitate safe and productive interactions between humans and computers or other devices.¹⁰ I look forward to working with others on this robust agenda. The CFPC’s Outcomes of Training project (www.cfp.ca/content/64/11/866)^11,12 and work by the Professional Development and Practice Support division will be instrumental in helping to shape this.

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