I want to be clear. I have not taken the stand that the complete physical exam should not be taught to medical students. I just think that the article noted above in the Australian journal should make us consider about what we are doing and not just assume that what has been taught students since the distant past is what we should be continue to do into the distant future. What we should teach to students is that what we should be doing, as physicians, evaluating and treating patients, be only in the patient's best interest. For example, in teaching the physical exam there are many, many components in each of the anatomic systems which we detail and expect the student to learn and perform correctly. Not all of these components have been rigorously tested for value. Certainly, in these days when a physical finding which might be thought by the physician to be abnormal can lead to a series of expensive and risky tests leading to a result which indicates that the physical finding was imagined, insignificant or benign and the finding did not really contribute anything to a final diagnosis or treatment. Beyond this potential misuse of resources, excessive use of the physical exam can be unwarranted and almost an abuse within the doctor-patient relationship, perhaps for benefits more for the physician than the patient.

Let's just think of an example or two. Is a physician performing a breast exam on a patient with no risk factors for cancer on a female under the age of 30 performing the exam in the patient's best interest? How about the physician performing a routine vaginal exam and pap smear for a woman who has had her cervix previously removed? In whose interest was that exam? Even routine annual physical exam as a screening procedure is now controversial in terms of patient benefit vs benefit for the physician..

"Laying on of hands" particularly warm hands is doubtless, in most cases, an important way for the physician to communicate an understanding and compassionate bond with the patient and in one form or another should never be abandoned.

What is so important in teaching medical students about the physical exam is instructing them not to perform it blindly and without thinking out the necessity for performing each step. The exam should never be performed mechanically. Students should understand they must have in most cases considered a differential diagnosis based on the history or previous findings and to understand with each step in the physical exam its value for identifying a diagnosis. To perform a complete exam otherwise in an unthinking manner is an insult to the patient's right to physical privacy which he or she has temporarily given up for the exam.

With regard to the ethics, performing the history and physical exam should always be done in the patient's best interest. Any interest other than this may well be unethical. There is more to the patient's interest than simply doing a history and doing a physical exam. It should be a professional goal to make the exam meaningful and as much as possible to avoid unnecessarily harmful consequences. That is why it doesn't hurt to step back and think about what as teachers we should be teaching our medical students. The act of challenging the physical exam is a worthy activity. ..Maurice..

I believe we need to segregate this question into three issues. First, should be continue to teach and require medical students to perform complete physical examinations? Secondly, should such an examination be performed on every patient and, as a corollary, to whose benefit is it when done? Finally, of what relative use is such an examination in 21st century medicine?

As someone who has taught courses in Physical Diagnosis in at least two different medical schools and practiced Internal Medicine for many years, I truly believe that both learning to do it, and performing it "appropriately," is invaluable to both student and physician, as well as the patient (well beyond the "laying on of hands"). A physical examination is the logical extension of our understanding of anatomy and physiology; "when you press here, and it hurts, what could be causing it?" Beyond this, though, not every location where a patient needs to be treated has a lab or imaging standing by. We will certainly need to run appropriate tests, but after a thorough H&P, these should be directed toward limiting our working differential diagnoses, not blind reliance upon technology to do our job for us. I remember when I learned how to fly an airplane. I had to learn to fly by "needle, ball and compass," despite having a "glass cockpit," because it was an article of faith that eventually, every little black box would fail and we had to be able to fly without them. Try making a diagnosis in a remote village in Africa, or Appalachia, for that matter, without the ability to perform an adequate physical examination.

Should such an examination be performed upon every patient? No, of course not. Just as our progress notes bet shorter as we move from medical student, to intern, to resident, and finally to attending status, so our examinations become more directed to the problem at hand. Except in unusual circumstances, it would be silly, not to mention potentially unethical to perform a vaginal examination on a patient complaining of chest pain or headache (yes, I know there are exceptions but I'm not dealing with them here). Still, while I believe there is little more important than a good history, I have frequently found things on physical exam that the patient never told me about, didn't know about, or were reluctant to discuss and I may not have arrived at the correct diagnosis or ordered the appropriate tests without performing the examination.

As an additional comment regarding the medical-legal aspects of the examination, and as an attorney, it should be remembered that while Lorraine's comments are accurate, they overlook the reason why the lack of such an examination would become a legal nightmare for the defense. It is because the performance of such an examination has become, by our own actions, the "standard of care." It is the breach of this "standard" that is tested in an action for medical malpractice. Therefore, if we were to decide, as a profession, that such an exam is no longer indicated, and having made such a recommendation proceed to follow it uniformly, that would then become the standard of care, and cause no legal problems that did not already exist.

Finally, we come the relevance of the "complete," general physical examination to medical care in the 21st century; where our technology has brought us to the point of the creation of synthetic life. I will be the first to admit that there were many times when I examined a patient's heart, lungs and abdomen in my office, among others when, having taken a thorough history, I already knew what was wrong with the patient and what tests I was going to perform, if any. I also knew that the patient expected the exam, and would feel significantly less confident in my diagnosis and treatment if it were not performed. Moreover, I was rarely, if ever, surprised by the findings of such an exam. Still, learning and performing a physical examination is as relevant today as it was when Sir William Osler wrote; “Observe, record, tabulate, communicate. Use your five senses. . . . Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.” Ultimately, all technology will fail (observe BP and the spill in the Gulf, the Challenger explosion, etc.) and we will be left with what we began with - a physician and a patient. Whether we justify it on this basis alone, or in the larger sense of test utilization and cost effectiveness, the result is the same - the physical examination should remain.

Excellent question.

The physical examination is like every other- it's only of value in the context of the clinician's knowledge and ability to interpret the results. It's a bit like ethics and law- we can teach it all we want in the first two years yet when the students arrive on the ward and echo and xray replace auscultation then clinical examination skills atrophy.

To me personally- it's very valuable but then I trained in the second world with limited technology.