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When performed well, the clinical exam (history and physical) feeds the diagnostic reasoning, testing, and therapeutic decision-making process. It is the key entry point when interacting with patients and drives much of the care that follows.
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However, the data accumulated is only useful when it is done in an accurate and complete fashion. The focus of this book is to describe foundational skills that you will need in order to provide clinical care. Achieving competence requires practice, feedback, and refinement.
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Why Obtain a History and Perform a Physical Exam?
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It seems important to take this on from the outset, as time pressure, technology, and questioning about what constitutes an appropriate exam and why we do it have drawn increasing attention. Our goal in this book is to teach about elements that have value. Doing something “just because” makes no sense and is not a good use of time or other resources. By the same token, thoughtful and skilled interactions with patients can provide an effective road map for guiding clinical care. These person-to-person interactions are also moments of connection which remind us that human beings are at the center of healthcare. Furthermore, while technology offers great information and insights, indiscriminate use can drive up costs and provide less than helpful guidance. And even a powerful tool like AI is dependent on core data to drive its recommendations. If that information (including the clinical exam) is incorrect, the subsequent guidance can be misleading (ie. garbage in, garbage out).
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We are also living in a moment of increasing distance from one another, with the US Surgeon General, Dr. Vivek Murthy, noting that, “Loneliness and isolation represent profound threats to our health and well-being.” In a sense, medicine too is suffering from a crisis created by clinical distance and disconnection. Physicians value one-on-one interactions, yet many aspects of the healthcare system create barriers between ourselves, patients, and colleagues. Technology (eg, the electronic medical record, instant messaging) provides tools that simultaneously enhance our ability to deliver elements of care, while also acting as distractions that can create distance between all of us. Healthcare organizations, reimbursement, and compensation can prioritize productivity over presence.
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Seen in this context, the clinical exam is a tangible way of truly being with another person while collecting key information. Humans are delightfully quirky, such that the way in which they describe symptoms often requires an open and tuned in human ear to truly understand and contextualize their stories. Physical connection, providing comfort and healing through touch, can only be delivered when you are next to another living soul. This provides additional impetus to learn and utilize core bedside skills, which can be applied in a pragmatic fashion to the care that you deliver. This will also help you to become better doctors and afford you with defined moments that rejuvenate and humanize. Helping others ...