On Reading Harrison’s Principles of Internal Medicine for the Last Time – Chapter 2

Physical Examination page 2

“The patient must be examined from head to toe”

That was true when we were medical students in 1973 and perhaps for fifteen years after but patients became wary of doctors and with some justification as evidenced by Larry Nassar or the late University of Michigan’s former team physician.

During my internship there was a very famous physician who insisted on doing rectal exams on all the recently admitted patients while we were on rounds and with no permission and no privacy. At the time we though it was unusual as most of the patients on this service were terminal, but we reasoned that this man had a good valid reason and was compulsive and would be loath to miss any tumor hiding in the rectum. He never checked for occult blood.

If he wanted to be compulsive, he should have examined the eyes with a portable ophthalmoscope which would be an acceptable outlet for his OCD.

As I have matured in medicine, I realize his behavior to be two standard deviations from the mean. But if we blew the whistle and spoke truth to power in the medical hierarchy of a world-famous place our careers would be over, and we would not be believed any way.

            When we were in training and were called to do a consult on a person for something like hypertension and picked up an incidental breast mass, we thought we were a doctor’s doctor.

            Now it must be a focused physical, to do otherwise is foolish.

            Still, I recall as a third-year medical student being assigned to a kind family physician. I was to see an eighty-year-old woman admitted for the stomach flu and dehydration. I did a complete exam and found a lump in her right groin. Her bowel sounds were high pitched and tinkling. I looked at her stomach x-rays and the film showed black cloud like structures resembling the negative of an Ansel Adam’s landscape. I reviewed Sir Zachary Cope’s “Early Diagnosis of the Acute Abdomen” and made a diagnosis of a bowel obstruction from an incarcerated femoral hernia.

            I told the old physician on rounds the next day. He smiled and called me an “eager beaver.” But he put his hand on the patient’s groin and realized I was correct. The patient went to surgery and recovered nicely. I was ecstatic. Perhaps I had what it took to be a good physician.

            But the physical exam as classically taught is an anachronism. With cat scans, ultrasounds, and MRI’s the physical exam is not as important today.  The medical history and listening to the patient and ordering the correct imaging study has become more important.

            Once more, the laying on of hands are now gloved in prophylactic latex.

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