Must Doctors Still Examine Patients?

Even as we enter the new millennium with a dizzying array of technology, the question posed in the title of this essay seems unthinkable and preposterous. Of course doctors must still examine patients! Where would medicine be without the physical examination? Indeed, "examining" patients may extend to the taking of the medical history, also fundamental to the practice of medicine. But perhaps the better question to ask is, "Is there potential for the physical examination to become obsolete, unnecessary?" Although most physicians might cringe at the thought, the author believes that yes, there is such potential. Given the fundamental and central nature of the physical examination in the practice of medicine, we are then forced to reconsider the role, perhaps even the very soul, of the physician, in the practice of medicine.

My perspective is that of a pediatric cardiologist with a sort of multiple personality: young and technology-fed, a specialist in cardiac ultrasound in children, but also the author of a book on cardiovascular physical diagnosis [1, 2]. As a disciple of both technology and physical examination, I will attempt to provide views from both camps, as well as a personal perspective. Many of the scenarios will be drawn from the practice of pediatric cardiology, which relies heavily on technology and with which the author is most familiar.

Definition of Physical Examination

What is physical examination? Broadly speaking, it is the study of a patient using one's senses, often with the aid of an instrument. Mosby's Medical and Nursing Dictionary defines physical examination as:

[An] investigation of the body to determine its state of health using any or all of the techniques of inspection, palpation, percussion, auscultation, and smell. The physical examination, medical history, and initial laboratory tests constitute the data base on which a diagnosis is made and on which a plan of treatment is developed. [3]

The boundaries of physical examination are not entirely clear. For example, using the stethoscope is traditionally part of the physical examination. In assessing vision, even using an ophthalmoscope or more sophisticated equipment to enhance the senses--lenses and slit lamps--is still considered physical examination of the eye. But something like echocardiography, the ultrasound examination of the heart, is considered "testing," because it does not enhance the senses but rather, converts reflected sound waves into decipherable images. The degree of invasiveness also seems to distinguish physical examination from testing. For example, few would argue that colonoscopy is a test, although it enhances the senses much like ophthalmoscopy; but it is invasive and is not used in the routine, day-to-day assessment of patients. For the purposes of this discussion, then, physical examination is performed with one's senses, although one can employ equipment designed to enhance the senses in a reasonably non-invasive and routine manner (for instance, the stethoscope).

History and Function(s) of Physical Examination

The centrality of physical examination in the practice of medicine is perhaps best illustrated by a brief overview of its history and a discussion of its purpose. The primary function of physical examination is diagnosis. All else in medicine--patient counseling, prognosis, medical and surgical treatment--rests on the diagnosis. Along with the medical history, physical examination is and has been the frontline tool for diagnosis. Physical examination is first and foremost based on observation, which would certainly be the oldest physical examination technique.

How far back does physical examination date? Observation almost certainly dates to prehistoric times, but early documentation of the use of observation and physical examination comes from the ancient Chinese and Egyptian civilizations. From China, the Huang-ti Nei Ching, or "Yellow Emperor's Book of Internal Medicine," is attributed to an era some 4,500 years ago. A patient's coloring, the condition of the tongue, and other detailed clinical observations, including auscultation, were important to Chinese diagnostics [4-6]. The Chinese may have been the earliest people to master pulse feeling for...