the exam table as the next student stepped forward. I watched as she coaxed and encouraged my three classmates through the exam and reviewed the process in my head from the safety of my chair.
A couple of years ago I moved my practice from one office to another. As I reviewed the charts of my relocated patients, transferring data from old to new, I noticed that although I had done a pretty good job in making sure that my patients got their recommended screening tests, I hadn’t done nearly as well on the hands-on component. Women should have a breast and pelvic exam performed annually, I was taught. Men over fifty should have a yearly rectal exam to look for prostate cancer. I saw that my adherence to those guidelines was pretty spotty. I was surprised by this oversight, but the trend was too strong to deny.
I puzzled over this. How could this happen? Some of it was a systems problem. In my old office there was no simple way to keep track of routine exams. To find the last exam I’d have to page through the last year’s worth of visits to see where I’d documented the results. And yet regular cholesterol tests were there. My patients over fifty had colonoscopies ordered or at least discussed. No, it was the breast exams, pelvic exams, and prostate exams that were missing. And I realized that despite the years of practice and the mastery of technique, I still found these exams uncomfortable to perform.On some level, I was still that medical student, reluctant to touch another person’s private places.
I’m not alone in this. There’s not a lot of data on this issue, but what’s there suggests that more of us are sending our patients for the screening test and dispensing with the hands-on component. In a study published in 2002, of the 1,100 women who went for annual mammograms in one facility over the course of a year, only half reported having had a breast exam done by their physician—ever. And while rates of mammography have increased over the past twenty years, rates of physician breast exam have declined.
Is that all due to the awkward intimacy of the exam? Probably not, though research has shown that it plays a role. Instead, the development of newer and better technologies—the mammogram, ultrasound, most recently the MRI—has caused doctors to doubt the value of what their hands can tell them. Why deal with your own embarrassment, the possibility of patient embarrassment, and the difficulty of interpreting the fuzzy pictures generated by touch when a study can show you the inner structures of the body with more precision and accuracy?
Why indeed? I’ll explore some of the answers to this increasingly urgent question in the next chapter.
CHAPTER FOUR
What Only the Exam Can Show
A s the skills required for an expert physical exam have become more and more rare, both among medical students and among practicing physicians, what has been lost? Among doctors, this is a topic of passionate debate.
On one side are those who argue that the demise of the physical exam is a natural consequence of progress. They say that the exam is just a charming remnant of a bygone era—like cupping (attaching warmed cups to the skin until blisters are formed) or bleeding or mustard plasters for colds—now replaced by an ever enlarging menu of technologies that provide better information with greater efficiency and accuracy. Affection for this discredited practice is characterized as pointless and sentimental.
On the other side are the romantics: doctors who see the physical exam as part of the long tradition of caring in medicine and cherish the profound connection between doctor and patient when linked by a well-placed hand and a warm heart. They see those who think otherwise as soulless technicians.
In the middle are the rest of us who simply want to understand what’s been lost. How large a role did the physical exam once play in making a diagnosis? What are we missing in the modern version of medicine that somehow
A couple of years ago I moved my practice from one office to another. As I reviewed the charts of my relocated patients, transferring data from old to new, I noticed that although I had done a pretty good job in making sure that my patients got their recommended screening tests, I hadn’t done nearly as well on the hands-on component. Women should have a breast and pelvic exam performed annually, I was taught. Men over fifty should have a yearly rectal exam to look for prostate cancer. I saw that my adherence to those guidelines was pretty spotty. I was surprised by this oversight, but the trend was too strong to deny.
I puzzled over this. How could this happen? Some of it was a systems problem. In my old office there was no simple way to keep track of routine exams. To find the last exam I’d have to page through the last year’s worth of visits to see where I’d documented the results. And yet regular cholesterol tests were there. My patients over fifty had colonoscopies ordered or at least discussed. No, it was the breast exams, pelvic exams, and prostate exams that were missing. And I realized that despite the years of practice and the mastery of technique, I still found these exams uncomfortable to perform.On some level, I was still that medical student, reluctant to touch another person’s private places.
I’m not alone in this. There’s not a lot of data on this issue, but what’s there suggests that more of us are sending our patients for the screening test and dispensing with the hands-on component. In a study published in 2002, of the 1,100 women who went for annual mammograms in one facility over the course of a year, only half reported having had a breast exam done by their physician—ever. And while rates of mammography have increased over the past twenty years, rates of physician breast exam have declined.
Is that all due to the awkward intimacy of the exam? Probably not, though research has shown that it plays a role. Instead, the development of newer and better technologies—the mammogram, ultrasound, most recently the MRI—has caused doctors to doubt the value of what their hands can tell them. Why deal with your own embarrassment, the possibility of patient embarrassment, and the difficulty of interpreting the fuzzy pictures generated by touch when a study can show you the inner structures of the body with more precision and accuracy?
Why indeed? I’ll explore some of the answers to this increasingly urgent question in the next chapter.
CHAPTER FOUR
What Only the Exam Can Show
A s the skills required for an expert physical exam have become more and more rare, both among medical students and among practicing physicians, what has been lost? Among doctors, this is a topic of passionate debate.
On one side are those who argue that the demise of the physical exam is a natural consequence of progress. They say that the exam is just a charming remnant of a bygone era—like cupping (attaching warmed cups to the skin until blisters are formed) or bleeding or mustard plasters for colds—now replaced by an ever enlarging menu of technologies that provide better information with greater efficiency and accuracy. Affection for this discredited practice is characterized as pointless and sentimental.
On the other side are the romantics: doctors who see the physical exam as part of the long tradition of caring in medicine and cherish the profound connection between doctor and patient when linked by a well-placed hand and a warm heart. They see those who think otherwise as soulless technicians.
In the middle are the rest of us who simply want to understand what’s been lost. How large a role did the physical exam once play in making a diagnosis? What are we missing in the modern version of medicine that somehow
Similar Books
