Banner by Aanika Vallabhaneni

Lost in the Lab: Rethinking the Role of Physical Exams in Modern Medicine

by Zola Mazzucato

After being treated for pneumonia a week prior, a middle-aged woman returns to the hospital with difficulty breathing and a fever. Once admitted, she is started on IV antibiotics. The next day, she complains of her legs feeling weak and more back pain than usual. Due to her history of chronic back pain, her symptoms are pushed aside without concern. But soon after, her fever spikes and her white blood cell count drastically increases. The medical team performs a CT scan, expecting to find an abnormality in her lungs that would explain her worsening infection. Instead, they discover an abscess on her spinal cord. 

If a simple physical examination had been performed earlier, the medical team would have found that the patient had a loss of sensation and reflex ability in her spinal cord as a result of the lesion. Luckily, she would survive this visit, but this was far too close a call for an entirely avoidable mistake. This woman’s story shows that no lab work or scan can replace the hands, eyes, or ears of a clinician – the art of medicine begins at the bedside, not the machine. 

Medicine has come a long way – it wasn’t too long ago that doctors were prescribing bloodletting for a classic headache or mercury pills to treat the over-encompassing list of day-to-day illnesses we suffer from. The origins of the physical exam date back to 1760 in Greek medicine. The physical examination did not become a standard practice in the U.S. until the development of formal medical education. By the late 19th century, advances in medical technology became the new diagnostic approach. The field of medicine was completely transformed by inventions of the microscope, medical imaging (MRIs, X-rays, CT scans, etc), and automated lab testing.  While these technologies have opened doors to incredible medical discoveries, they have also closed the door on some of the most humane aspects of care – the physical exam and the patient’s story.  Provider overload and an increasing reliance on technology are disrupting the time and attention patients deserve. 

A study conducted in Beijing tested general practitioners on their habits while performing the physical exam, and the results were striking. A total of 682 consultations with 11 general practitioners were recorded. Physical examinations were performed in just 126 of the consultations (15.8%). This is wildly insufficient. More time and commitment should be allocated for improving the quality of physical examinations in primary care. Studies have shown that more time spent with the patient, including conducting the physical examinations, leads to better patient satisfaction. For example, another study found a greater likelihood of patients feeling they had inadequate time with their physician in visits scheduled to last 5 minutes compared with visits scheduled to last 10 and 15 minutes, respectively. 

The physical exam was once the root of diagnosis. A careful examination and the patient’s narrative were the tell-all, usually followed by testing. You can imagine that an ER physician responsible for dozens of patients in just one shift may feel they simply do not have enough time for a thorough exam or extended conversation. Instead, doctors who are faced with a sick patient run directly to diagnostic imaging and lab tests for a diagnosis, skipping the exam altogether. The exam should be the foundation – technology is only its supplement. Without the physical examination, not only is a doctor's ability to make a quick and efficient diagnosis jeopardized, but it also changes how patients experience care. According to recent studies, providers spend more time on screens than with patients. In fact, one study shows that residents spent 364.5 minutes (50.6%) of their shift time using computers, compared with 67.8 minutes (9.4%) interacting with patients. This large reliance on electronic medical records has vastly shifted the way medical professionals communicate – consultations, for example, are almost entirely performed online, leaving less face-to-face collaboration and no patient-to-physician connection. The pressure to complete charting and documentation points to a larger systemic issue: a healthcare structure that values efficiency metrics and documentation over the human touch that defines good medicine.  

This shift has pushed scholars to increasingly recognize philosopher Michel Foucault's concept: “the medical gaze.” The medical gaze model suggests that doctors focus only on selecting the biomedical elements of patients’ problems, filtering out all other elements of a person’s life story. Doctors are becoming concerned that modern medical education is putting too much emphasis on disease and diagnosis rather than bedside manner and direct time with the patient. It is becoming increasingly clear that medical education emphasizes mastering the technical language of medicine, which can cause students to lose the compassion and motivation they initially had. Dr. Nancy Angoff is the dean of students at Yale Medical School. She observes over one hundred students a day, overhearing constant references to patients as their condition and location. Dr. Angoff says, “Medical schools don’t teach you about the patient, they teach you about the disease. I wanted to emphasize the patient, right from the very first day.” In order to implement these values into her students, she wanted her students to shift their focus to be against the disease and the depersonalization of the patient, and instead emphasize the differentiation between the patient’s story and the story that doctors create from it. 

Medicine, from the start of time, has been an art that relies on patient-to-provider trust and collaboration. Reducing patients to data points puts medicine at the risk of being stripped of one of its most vital factors: humanity. It can be argued that referring to medical technology as a supplement is abandoning innovation, but really, it just means we need to find other ways to integrate it, with the goal of restoring patient-to-provider relationships that have been lost. Through re-guiding the art of bedside care, medicine can reclaim its balance between science and compassion and ensure patients are not just cases, but human beings. At its core, medicine and its future depend on restoring the balance between embracing the power of technology while preserving the irreplaceable human connection found in the physical exam and the patient’s story.