Leading Off: Why the physical exam is still really necessary

Leading Off: Why the physical exam is still really necessary

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Oct 01, 2008


David Robbins, DVM
When Ludwig, a 6-year-old Boxer, came in for his annual vaccinations and physical examination, he was showing signs of abdominal discomfort and had difficulty walking on his hindlimbs. My physical exam findings were normal except for apparent pain on abdominal palpation and unilateral cryptorchidism. Thus, I suspected that Ludwig had a retained testicle and that it could be causing a problem. I reviewed Ludwig's medical chart and could find no mention of a retained testicle. In fact, the medical record identified Ludwig as neutered.


Duke's elusive diagnosis: An illustration of the importance of history taking
I discussed my findings with the owner, who proceeded to tell me that in all the years of coming to the practice for exams, no one had ever mentioned the retained testicle. Furthermore, the owner said that no one had ever examined Ludwig's private region. She said, "They always seemed in a hurry to just vaccinate."

It turned out that Ludwig's retained testicle was cancerous. Unfortunately, by the time I saw Ludwig, the cancer had already spread throughout his abdominal cavity. However, it makes you wonder if a complete physical exam could have prevented this had one been done sooner.

OUR MOST FUNDAMENTAL DIAGNOSTIC TOOL...

The physical exam is the routine assessment of a patient by using our five senses and minimally invasive techniques, using for example a stethoscope, not a colonoscope.1 Together with the patient's history, the physical exam helps us determine whether additional diagnostic tests are indicated, and, if so, which tests will be most useful. The physical exam is among the few commonalities in veterinary medicine, practiced by every veterinarian trained in every country. Anyone who has practiced or observed veterinary medicine in an economically challenged setting knows the physical exam is often the only method available for diagnosing a patient's illness.

...IS BEING DEVALUED

However, as technology continues to evolve in veterinary medicine, I am concerned about the future role of the physical exam in our profession. From advanced imaging in veterinary referral centers to sophisticated tests now available routinely in outpatient settings, technology has altered the way we diagnose, treat, and palliate disease. Are we putting too much emphasis on technology instead of on the physical exam? And, if so, is it changing the way we view the physical exam?

In my opinion, we are beginning to see the role of the physical exam de-emphasized. I have noticed more practitioners spending less time obtaining or reviewing a history and performing cursory physical exams in sick and healthy patients almost out of a need to be loyal to the process rather than valuing the information gathered. In modern veterinary medicine, diagnostic tests have supplanted clinical skills. Rather than relying on detecting a murmur during auscultation, we use an echocardiogram to tell us whether a patient has mitral insufficiency. And magnetic resonance imaging (MRI)—not a neurologic exam—tells us whether our patient has a brain lesion.

It may be easy to say that the physical exam is losing some of its potency because we are busier than ever and have less time to perform thorough physical exams. Although definitely a factor, our lack of time only partly explains this change. A decreased emphasis on physical exam skills in veterinary schools, the fear of uncertainty, the availability of sophisticated diagnostic tests, and even financial factors also play roles in the demise of the physical exam.

Veterinary school de-emphasis

In talking with new graduates over the years, I've concluded that many veterinary schools are not emphasizing the physical exam. I remember taking a physical diagnosis class as a sophomore in veterinary school. A general practitioner taught the course, and she had mixed feelings regarding the value of the skills she was teaching. The course was a pass-or-no-pass, one-unit class sandwiched between rigorous physiology and anatomy courses. It was a fun but devalued class, and we students viewed it as a rest stop, a break from the rigors of the important subjects.

In that class, we did learn about the importance of a wellness exam, but we spent little time on abnormal findings because those were to be covered in clinics. Unfortunately, I encountered similar attitudes toward physical diagnosis in clinics. Many of the interns and residents focused on teaching the value of running diagnostic tests instead of conducting good physical exams. Who had time to perform a complete physical exam? We all had to check on 12 patients and participate in rounds.

As today's clinical faculty faces increasing time constraints, it's likely that even less time is being spent on teaching physical diagnostic skills. Another reason educators may not be emphasizing these skills is because they lack confidence in their skills. Some teachers' greatest vulnerabilities may be in the clinics.