Don’t be out of touch: An osteopathic physician discusses the importance of the physical exam
Posted: July 17, 2024
Linnette Sells, DO, FAOASM, ’82, serves as a member of ATSU’s Board of Trustees. She is a former emergency room and urgent care physician and former team physician for Georgia Tech. An Operation Desert Storm veteran, Dr. Sells served in the U.S. Air Force as chief of the emergency department at MacDill Air Force Base. Dr. Sells also served as ATSU-Kirksville College of Osteopathic Medicine’s (ATSU-KCOM) family medicine clinic director and faculty member from 1986-90.
As told by Dr. Linnette Sells
As a DO, I was taught the skills of physical exam with emphasis on touch and palpation. I learned the importance of subtle changes in the musculoskeletal and lymph systems affecting a patient’s health. I learned every human system affects the whole person. During my years in practice, I have witnessed the deterioration of these valuable skills in lieu of ordered testing based on history and chief complaints.
I have recently retired after 40 years in practice. Lab tests, X-rays, CT scans, and MRIs are now being ordered on patient complaints, often prior to the patient being seen by the doctor or provider. Artificial intelligence (AI) programs may be used to diagnose and work up patients again without physically touching the patient. In the past, we didn’t have this technology readily available, and we used physical exam findings to guide our diagnosis and treatment. So, should the physical exam be negated? I do not believe this valuable tool should be eliminated from our arsenal in caring for our patients.
An example of a patient who needed a physical exam was a 10-year-old male with ankle pain and inability to bear weight. His mother wasn’t happy with him because he was seen for an ankle sprain six months prior and had not been doing his prescribed exercises. He complained the night before of a possible re-injury but had no significant trauma. He was seen by his pediatrician and had an X-ray taken, which was negative. An ACE wrap was applied, and he was told to do activity to tolerance.
I saw the young man later that day because he was complaining of increased pain and his mother wanted him to get pain medication. On my physical exam, the skin of the ankle joint was warm, and he was tender to palpation along the entire ankle mortise with no ecchymosis or ligamentous laxity. His pain markedly increased on checking the joint’s range of motion. Due to the joint exam findings, I ordered labs, which showed elevated white blood cell count and erythrocyte sedimentation rate, and later, the C-reactive protein (CRP) was markedly elevated. This young patient had a septic joint and osteomyelitis, not an ankle sprain. He had emergency surgery.
Another example of the need for a full physical exam was in the follow-up of a 72-year-old male who complained of an uncontrolled cough, which had been worse at night for a month. He was seen in two prior office visits by other providers who treated him for bronchitis with steroids, antibiotics, and cough medication. The electronic medical record (EMR) for the prior visits stated the lungs were clear and heart had a normal rhythm.
On my physical exam, I noted the patient had decreased breath sounds in lung bases, a third heart sound, and irregular heart rate, which was not picked up by the medical technologist who used an automated cuff. He also had +2 edema of his legs bilaterally. His thorax had tightness and somatic changes. This man had early congestive heart failure due to atrial fibrillation, not bronchitis.
The efficiency of EMR with templates simplifies the documentation of physical findings, but it is so easy to click the necessary categories without really doing the entire exam of that system. An example of an incomplete exam was with an 18-year-old male I saw for severe abdominal pain and fever. He was seen 24 hours prior in a local emergency room and told he had acute gastroenteritis, which was going around his school at the time. He said they asked about his symptoms, which were fever, nausea, vomiting, and abdominal pain, and he had vital signs taken, blood drawn, and IV hydration, along with antinausea medicine. He was told he had a reactive high white blood cell count, and the rest of his labs were normal.
My exam exhibited a young man in distress trying to maintain a “quiet position” with tachycardia, a rigid abdomen, decreased bowel sounds, and a temperature of 102. Deep palpation elicited rebound and guarding. My diagnosis without labs was acute appendicitis with probable rupture/peritonitis. His ER records were a five-page EMR document showing a very thorough exam had been completed, including head, ears, eyes, nose, throat, lungs, heart, abdomen, and neurological exam with muscle and deep tendon reflex testing. According to the document, all findings were normal. However, the patient stated no one performed a physical exam; they just ordered labs and an IV.
Before the mandatory male genital exam was removed from the pre-participation physical, I found several testicular masses, which were early cancer, inguinal hernias, and a syphilis lesion. During those pre-participation exams, also finding a heart murmur or enlarged lymph node could be life-saving. My staff asked why it took me longer to do the exam than other providers who only took a few minutes to sign the athlete’s form.
My first day on a student rotation at an Air Force base clinic, I awaited my first patient who was late. He shuffled in and told me he wanted to start an exercise program because he had become a couch potato following his military retirement. He was mid-40s, seemed to have a very slow gait, and struggled with muscle weakness. I proceeded to do a complete physical exam. He had a positive Babinski sign and ankle clonus – I had never seen positives! He also had poor muscle tone and weakness with testing. I had to take this information to my attending physician who was already unhappy because I was so slow. I told him my findings and suspected my patient had amyotrophic lateral sclerosis. He laughed and shook his head, muttering about medical students always looking for zebras. On examining the patient, he reluctantly agreed, and later, the neurologist confirmed the diagnosis.
When I was running the ATSU-KCOM family practice clinic, we admitted a 10-year-old female with vague abdominal pain and dehydration due to nausea and vomiting. I tasked our family medicine resident to do a full physical exam to see if we could make a more specific diagnosis. Surprisingly, the patient had hypertensive changes on examination of her eye grounds and cardiomegaly with high blood pressure. She also had somatic dysfunction of thoracic and lumbar areas. Based on these unusual findings, we checked her norepinephrine level. This led us to look for a paraganglioma, which was found in her abdomen and surgically removed.
A 45-year-old female CrossFit athlete went to the ER with 10 out of 10 pain in her left pelvis. Labs and an abdominal and pelvis CT scan were ordered. She stated the ER provider did not touch her hip. The scan was negative, and the only positive lab was plus 1 leukocytes in her urine. She was treated with an antibiotic and told to follow up with a urologist.
I saw the patient in the urgent care clinic afterward – she entered using her grandmother’s walker. On physical exam, she had severe palpable pain in her left pelvic innominate. The X-ray was negative, but because of her pain level, I ordered a CT scan and labs looking for markers of bone inflammation. Her CRP and erythrocyte sedimentation rate were markedly elevated, and the CT scan was read as inflammatory changes in the bone marrow. A bone biopsy showed acute lymphoblastic leukemia.
“My cancer diagnosis would have been markedly delayed if Dr. Sells had not immediately examined and pinpointed the source of my pain.”
– A 45-year-old female patient and CrossFit athlete
Recently, I moved and went to a new provider. I asked for an annual physical exam. My vital signs were taken, and I filled out a medical history and review of symptoms. I happen to be a 70-year-old CrossFit athlete, so I don’t look my age. My provider looked in my ears and listened quickly to my lungs and heart. That was it! The provider then ordered a few basic labs and asked if I was up to date on my health maintenance testing: colonoscopy, mammogram, etc. I’m sure I’m not the exception. Essentially, I could’ve had a televisit for this exam.
Telemedicine is now being offered in many clinical settings, and it has its uses. However, as a “hands-on” DO, I have found this very difficult because of the possibility of a missed or erroneous diagnosis. Even a simple complaint of a sore throat without being able to visualize or palpate makes for a tentative diagnosis. I tended too often to recommend the patient be seen in the clinic.
One of the common complaints against doctors in Google reviews from patients is the fact they were never touched, which means they had no physical exam. My husband is also a DO and specialized in physical medicine and rehabilitation. He always did a thorough neurological and musculoskeletal exam. His patients were amazed and often stated they’d never had that extensive of an exam, even though they had multiple surgeries for their complaint.
I can cite many more examples of this medical trend. While the cases I highlighted in this story had some unusual diagnoses, they could have been any typical patient visit. As providers, we all tend to succumb to the pressures of clinical practice. With the number of patients we must see in a day, the ease of possible false documentation in EMR, and the notion testing can replace the need for physical exam, we are now on a downward spiral that could shortchange our patients and delay or miss diagnoses impacting their medical care and health. What role will AI play in the healthcare of our patients? Can we use these great technologies as tools to improve each patient’s care without sacrificing the patient- doctor relationship and provide compassionate healthcare?
As DOs and ATSU-educated healthcare providers, we have been tasked with a mission statement to provide whole person healthcare. The tenets of osteopathic medicine say structure and function are reciprocally related. I believe we should be leaders in bringing back the physical exam as it is a strong and vital component of a patient’s healthcare.
I entreat and challenge every one of my colleagues and future healthcare providers to re-examine their mindset on office visits and the physical exam. Let us not lose the skills we learned at ATSU and bring back the physical exam.
BENEFITS OF PHYSICAL EXAM
- Guide the provider in ordering necessary versus unnecessary testing.
- Find physical manifestations to aid patient preventive healthcare.
- Improve diagnosis by being able to judge patient reaction to exam.
- Build rapport, trust, and communication through touch and eye contact.
- Add more information into AI programs to improve diagnosis and treatment.
- Aid additional providers with accurate physical findings for comparison.
PHYSICAL EXAM EDUCATION AT ATSU
“The physical exam is essential to the development of the doctor-patient relationship, which is central to the practice of medicine. The physical exam is also a cost-effective way to evaluate and guide the use of necessary technology. Technology offers another tool in providing care, but it will never replace the doctor at the bedside who touches and converses with the patient to build a connection and alleviate human suffering.
ATSU-KCOM continues to teach the clinical skills needed to be the best bedside physician and, at the same time, incorporates the use of current technology to augment care. This high-tech/high-touch approach to medical education is part of what makes our graduates stand out.”
– Margaret Wilson, DO, ’82
ATSU-KCOM Dean
“ATSU-School of Osteopathic Medicine in Arizona (ATSU-SOMA) takes tremendous pride in training our students to excel in their osteopathic physical examination techniques as we prepare them to become osteopathic physician leaders in our nation’s most vulnerable communities. Our students’ current and future patients deserve the healing touch of human kindness that osteopathic medicine provides.”
– Sharon J. Obadia, DO, FNAOME, ’97
ATSU-SOMA Dean
“Teaching our students to provide hands-on, whole person healthcare is a hallmark of ATSU. A few years ago, a former classmate, who is an orthopedic physician and uses his hands to help patients daily, shared how he and all the other providers at a Florida health system were asked to attend a lecture on the importance of touching patients. This health system was getting so many negative comments from patients saying the doctor never touched them during their visit, experts were asked to come in and encourage the providers to perform physical exams – and this was before COVID.”
– Craig M. Phelps, DO, ’84
ATSU Chancellor