What if all the doctors had been like this one? What if we treated our patients like our own lives were at stake?
Let’ s go back to reality now. You have a very bad abdominal pain and you decide to go to the hospital. Without any overstatements, the image below is very close to what actually happens in our emergency rooms. Instead of focusing on the patient’ s needs and trying to understand his complaint, we rather launch series of expensive, useless and sometimes dangerous, tests where a simple patient history and proper physical examination would have been more than enough.
We can not in our modest review enumerate all the causes that pushed us away from our patients, nor can we nominate solutions. Thus, we will simply try to highlight the major challenges for physical examination. The first issue is the lack of research and the necessity and benefit of promoting it in classic bedside examination. The second point is about rationalizing the physical examination and applying the researches results in an Evidence-based approach. Finally, we will try to discuss the challenges of physical examination’ s assessment in medical school.
A lack in research There are many books dedicated to physical examination, with usually high-quality explanations and illustrations. From medical school textbooks to whole signs dictionaries, one can easily find a great reference to study from. Nevertheless, we are forced to state that the scientific value of the information and the quality of evidence is in many cases very poor. We mean that, apart from general principles agreed on, many of the presented statements, observations, rules and even tricks often result from the author’ s own experience, far from a strong evidence and with complete disregard to research findings and latest data. The reason behind this is beyond the authors of these textbooks and lies in research itself. Very few researches are conducted to study the bedside examination compared with other diagnostic tools. Infact, physical examination is only approached in its pedagogical dimension. It is considered more of an“ art” than a real science. Perhaps this is the reason that pushed some prestigious authors to name their books“ Art & Science” 1, 2, as to remind us that there is also a little science in it...
We look at physical examination only as a mandatory step in medical curriculum, taught only out of habit or tradition. Take a student who is having his first physical examination lecture; the joy and happiness of finally acting like a real doctor is very quickly replaced by the disappointment of noticing that none of his teachers really apply what they are teaching in their daily practices, not even a half of it! If that wasn’ t enough, these same“ teachers” pretend to have the ability to evaluate students... have you felt that frustration too? Sorry... let’ s go back to research.
As said earlier, the number of papers talking about physical examination is really small. We can mention three great initiatives that promote Evidence-based physical examination:“ The Rational Clinical Examination” systematic reviews series in JAMA( Journal of The American Medical Association) 3; the book“ Evidence-Based Physical Diagnosis” written by Steve Mc- Gee 4 and the Stanford25 education initiative 5. As a matter of fact, in 15 years, only about 70 articles were published in The Rational Clinical Examination. If you don’ t see how little this is, maybe it will help you to know that approximately 2000 new articles are indexed in PubMed every day 6!
The reason behind this lack in meta-analyses and systematic reviews is that the number of data available is very poor. Most of the studies include far less than 100 patients, sometimes only 2, and are old and conducted in questionable conditions. Even worse, we can evaluate the quality of evidence only after having done all the standardization and analysis, to often discover that the data is useless, discouraging researchers even more.
The initiators of the Rational Clinical Examination wanted to“ restore respectability to a part of medicine that seemed to have been eroding as academic and financial rewards went to those who most resembled scientists relying on expensive diagnostic tests and least behaved as physicians relating to patients”, said Drummond Rennie in his preface 3. According to Sackett, there are 5 main reasons behind the lack of research in physical examination field 7: 1- Designing investigations on the precision and accuracy of the medical history and physical examination is very arduous. First, we have to assemble a large number of appropriate patients, then proceed to their repeated examination by clinicians, either wide-rangingly experienced ones or those still in training, and
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