Missing a diagnosis made me realize the value of a thorough physical exam. It can often illuminate the cause of the illness.
Lifelong Learning in Clinical Excellence | September 13, 2021 | 4 min read
By Susrutha “Sus” Kotwal, MBBS, MD, Johns Hopkins Medicine
Ms. K was an 84-year-old woman in the emergency department for syncope. As her admitting physician, I went over a routine history, physical exam, and admitted her to the hospital. Due to her history, I was worried about a cardiac etiology for syncope and ordered an echocardiogram. I explained my thought process with her and asked if she had any concerns or questions. She didn’t, and seemed satisfied. I updated her primary care provider and her son, who both agreed with the plan of care.
The following day I changed service, so I reviewed her care through the electronic health record. I’ve developed this habit primarily to get feedback on not just interesting/rare cases, but also routine/easy cases as I thought Ms. K’s was. No significant abnormalities were found on the echocardiogram and the extensive tests she had in the hospital. However, an additional diagnosis showed up in my colleague’s note: a large breast mass! In the next few days, I was back on service and taking care of Ms. K. Here’s what I learned from this experience:
1. Include an initial thorough physical exam when you meet a patient.
Research suggests that a significant proportion of diagnostic errors arise from failures in bedside diagnostic reasoning, like failures in history and physical exam at the patient’s bedside. I thought I’d done an efficient physical exam when I met Ms. K in the emergency department, so I asked my colleague to show me what he’d done differently. I wanted to know how he’d picked up the left breast mass that I completely missed on my initial evaluation! My colleague had done an undressed exam (with her permission and with a chaperone) as part of an initial thorough physical exam, which resulted in the discovery of the mass on her left breast. I failed to do this in the emergency department and examined her from over the hospital gown to save time. I knew she was going to get an echocardiogram and felt my examination would be be redundant.
2. Develop your physical exam skills because it adds additional value beyond diagnostic abilities.
Once the mass on her left breast was found, Ms. K volunteered additional information to my colleague which helped with the diagnostic process. I asked Ms. K why she shared this information with my colleague who she had met for the first time and not with anyone else. Neither her son nor her primary care provider of 20 years was aware of the mass. Ms. K said, “I moved to America from Italy in the 1940s after the war. I’ve seen several doctors all around the world and no one has ever examined me like that before. I felt a connection with your colleague that I haven’t felt with anyone else. That’s why I wanted to tell him everything. I wanted to pour my heart out to him!”
The practice of medicine has been described as both a science and an art. Evidence based articles have been written about the utility of physical exam (i.e. likelihood ratios) as a diagnostic tool but there is a dearth of information on the use of physical exam to improve the human dimensions of care. Include physical exam as one of the tools to build the patient-physician relationship.
3. Utilize the physical exam as a ritual for caring and healing.
A ritual is described as a rite of passage, the crossing of a threshold, or a sacred event. The physical exam has been described as a ritual that’s beneficial for both patients and their clinicians. Multiple studies suggest patients often complain that no one fully examined them. I was guilty of cutting short this sacred ritual by examining the patient from over the hospital gown. Perhaps Ms. K sensed this and didn’t volunteer additional information with me about the breast mass.
4. Engage in the bedside exam as a method to reduce burnout.
In this day and age, healthcare professionals are pressed for time. This has led to reduction in time spent at the bedside by clinicians, which contributes to burnout and thus increases the chance of diagnostic errors. An initial thorough physical exam may not just be appropriate use of time, but could also contribute to reducing diagnostic errors and delays in patient care. This may add additional value and meaning to our work, reducing burnout and increasing the joy of practicing medicine.
Ms. K was referred to oncology, and further imaging showed extensive metastasis all over her body. She opted for hospice/comfort care and passed away peacefully in her home.
Edward Morgan Forster, in “Howards End,” wrote, “Only connect . . . And human love will be seen at its height!” For Ms. K, a thorough bedside physical exam was important to connect, was important for her need to be cared for, and was cathartic for the patient-physician relationship which ultimately contributed to the diagnostic process.
This piece expresses the views solely of the author. It does not represent the views of any organization, including Johns Hopkins Medicine.