Tuesday, February 1, 2022

Routine daily physical exams in hospitalized patients are a waste of time

 Rodman A, Warnock S. Point: Routine Daily Physical Exams in Hospitalized Patients Are a Waste of Time. J Hosp Med. 2021 Aug 18. doi: 10.12788/jhm.3670. Epub ahead of print. PMID: 34424194.

From the article:

The physical exam most frequently performed in the hospital today is the so-called routine daily exam. Generally, this involves passing a stethoscope fleetingly across the chest and abdomen, perhaps with some additional palpation of the abdomen. Cranial nerves II through XII may also occasionally be checked. This routine exam—and by extension, the templated physical exams that fill hospitalists’ documentation—not only lack an evidence base, but also are arguably harmful to patients. Such exams should not be part of a hospitalist’s daily practice. The most concerning aspect of a routine daily exam is that examination of an asymptomatic patient—for example, auscultation of the lungs of a patient admitted with lower extremity cellulitis—is fundamentally a screening rather than a diagnostic test. While little work has been done in the inpatient setting, decades of studies on outpatient screening exams demonstrate that very few of them are effective.  For example, a review of commonly used exam maneuvers in wellness visits concluded that “for the asymptomatic, nonpregnant adult of any age, no evidence supports the need for a complete physical exam as traditionally defined,” recommending against such popular maneuvers as lung and heart auscultation and peripheral pulse palpation...

In addition to potentially adding more risk, the routine daily physical exam represents time that can be better allocated. Medical residents spend the vast majority of their day at the computer, while spending less than 10% of their time at the patient’s bedside. Anything that takes up that valuable time, including a “routine exam,” is time spent not talking to the patient, learning about their symptoms, their fears, and who they are as human beings...

 Rather than a diagnostic exam that has potential downstream cost implications and consumes valuable time from an encounter, we suggest a return to a more traditional ritual of physical touch: sitting at the patient’s bedside, holding their hand, and speaking to them compassionately about their fears and hopes. This would be a far more valuable “routine” encounter to incorporate into the busy hospitalist’s day.

Rodman A, Warnock S. Rebuttal: Routine Daily Physical Exam. J Hosp Med. 2021 Aug 18. doi: 10.12788/jhm.3672. Epub ahead of print. PMID: 34424195.

From the article:

They argue that this exam might be helpful as a deliberate practice to improve skills for effective diagnostic exams. To this, we have two responses: the first is that the typical “routine” exam—a brief auscultation of the chest and abdomen—is performed frequently enough that additional practice should not be necessary for any practicing hospitalist. Performing a true full exam that would hone infrequently used skills, such as a full neurological exam, an orthopedic knee exam, or fundoscopy, comes at the expense of time spent talking to patients, as well as the potential harm of downstream testing cascades leading to adverse events. Second, we would argue that the real skill being developed is not “recognizing normal” but instead learning how to appropriately use physical diagnostic skills. Knowing precisely what exam maneuvers might be beneficial in a given hospitalized patient is incredibly complex, far more so than charts in evidence-based exam textbooks would suggest. It is this skill, not “recognizing normal,” that requires deliberate practice...

The physical exam was originally developed as a diagnostic tool, not as a method to connect with patients. However, this traditional “routine” exam has been taught in medical schools as normal ever since, with very little serious interrogation of its utility or downstream effects. Increased cynicism about the exam’s usefulness, in our opinion, reflects physician cognizance of actual disutility of routine exams, rather than pining for a halcyon era that never existed. In fact, we believe a more hypothesis-driven diagnostic use of exams enriches physical diagnosis. For instance, listening to the chest of a patient with cellulitis on intravenous fluids is no longer “just listening,” it is an exercise specifically looking for a finding that affects management. Patient-centered care means tailoring all of our care—including the physical exam—to the needs of the patient. Doing a cursory, routine exam day after day for every patient with the goal of “recognizing normal” is not patient-centered, but rather physician-centered.

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