HIV and ID Observations

A doctor and nurse examine children in a trailer clinic at a mobile camp in Klamath County, Oregon. Photograph by Dorothea Lange, October 1939.

A very interesting, quite scholarly perspective appeared in the NEJM last month called, “Strategies to Reinvigorate the Bedside Clinical Encounter.” Drawing plenty of attention on social media, it elicited the usual hand-wringing from clinicians who bemoaned the way modern medicine has evolved — away from direct care of patients and toward an ever-expanding reliance on technology for testing and communication.

With the hungry electronic medical record that always needs feeding, the innumerable administrative burdens placed on clinicians, and the simple fact that most doctors are paid per unit of service they document — not by time spent at the bedside or in the exam room — we simply don’t spend enough time with our patients.

Not enough time looking at them. Talking to them. Listening to them. Instead, we’re perched in front of that glowing screen, its shining flat-panel computer face named years ago by Dr. Abraham Verghese as the iPatient. Clever!

Why would more time with patients be so valuable? Because I strongly believe that there’s nothing worth more in an effective clinical encounter than taking a good history — and, if I may be so immodest, this is where we ID doctors shine. (It’s certainly not doing bedside procedures.) Since I’ve devoted a whole post to taking histories and spend a whole lot of time and energy with our ID fellows stressing the importance of history in what we do, let’s shift to another part of the direct clinical encounter, which is the physical examination (PE).

There are several opinions and perspectives about the PE that repeatedly come up in both the medical literature and in conversations with students, colleagues, and other health care professionals. Let’s take a look at five of them one at a time, starting with the beginners:

1. The Medical Student, the Learner

Wow, I’m going to have to learn how to use these new tools — stethoscope, reflex hammer, the ophthalmoscope …  Each time I see a patient, I’m so nervous about doing something wrong that I can barely concentrate on what I’m seeing, feeling, or hearing … Is that an S3? A systolic or diastolic murmur? What’s the difference between rales and rhonchi — I think I know what wheezes are … Is that 1+ or 2+ edema? What is shifting dullness again? Which cranial nerve are we testing when we ask them to shrug their shoulders, and why is it a cranial nerve anyway? And can the patients tell that I have no idea what I’m doing, basically all of the time? Oh, to have the confidence of the senior resident on this rotation, who somehow always knows what and how much to do! And the attending does even less …

2. The Pediatrician, the True Believer

The physical exam is absolutely critical … especially in babies! After all, they can’t tell you what’s wrong … A parent’s intuition (usually the mom’s, let’s be honest) is helpful, but still — she’s not going to pick up hip dysplasia, or the absence of a cornea reflex, or scoliosis, or a heart murmur … My entire career is filled with these pick-ups, each a little win for early detection … I can’t imagine a clinic visit without a good physical exam … And get the clothes off, please! No one can do an exam on a screaming toddler in a snowsuit …

3. The Proud Expert of the Physical Exam (Usually but Not Always Played by an Older Cardiologist)

Hey, have a few minutes to go to the bedside? Allow me to show you how the Valsalva maneuver differentiates between hypertrophic cardiomyopathy and aortic stenosis … And while I’m at it, listen how the handgrip exercise intensifies the mitral regurgitation murmur by increasing afterload, and note how you hear the aortic regurgitation murmur better while the patient is leaning forward and exhales fully … For my money, the hepatojugular reflux test is much better than peripheral edema assessments for volume status in chronic heart failure … And by the way, I’ve never met a patient in whom I didn’t carefully assess the neck veins … it’s just a matter of finding the perfect angle, ideal lighting, understanding the difference between the arterial and venous pulsations, and making sure you’re looking at the internal jugular waveforms, preferably while shining a light tangentially across the neck … Got that?

4. The Busy and Overworked and Beleaguered Provider at the End of the Day (We’ve All Been There)

I heard a systolic murmur … Let’s get an ECHO … because the data are really limited on the accuracy of what we hear in the office and what an ECHO shows anyway … and meanwhile, I have 10 prior approvals to complete and multiple disability forms to fill out and quality metrics to meet and in-basket messages to return and abnormal tests to follow-up on, and of course everything is required sooner rather than later … and how is this even possible in a 15-minute follow-up visit, especially when my 3:15 p.m. patient arrived at 3:45, insisting that they be seen even though I’ve double-booked my 4:00 p.m.?

5. The Orthopedic Surgeon

What’s a stethoscope?

If you want my take, I’m here to say that all of these views on the physical exam have validity — each has their place, their sound justifications. That busy doctor who moves quickly to order the ECHO? The cardiologists will get the ECHO too, even after all their fancy maneuvers. And show me an orthopedic surgeon who does a careful complete PE, listening for carotid and femoral bruits, doing a Romberg test, and percussing the liver span, and I’ll show you one who doesn’t operate often enough. A more comprehensive exam isn’t always better, despite what some old-timers say.

But clearly doing some aspects of the PE is almost always better than nothing at all — and there are two reasons why.

First, a physical exam targeted by the patient history can be immensely valuable. As an example, a memorable pick-up was thanks to a resident rotating with me in ID clinic. In seeing a patient in follow-up while he was still on intravenous antibiotics for endocarditis, she heard the murmur of aortic insufficiency while doing a careful cardiac exam. After confirming her findings, and noting that they were new since discharge, I contacted his cardiology and cardiac surgery teams who were understandably alarmed; they expedited his lifesaving valve-replacement surgery.

(She’s now a cardiologist, of course. You can be sure I sang her praises and cited this case when she was applying.)

Second, most patients want us to do them. One of my current colleagues, Dr. Mary Montgomery, was an ID fellow here a bit over a decade ago. Observing her physical exams, I noted she always looked in her patient’s ears, even when they had no ear complaints. When I asked her why, she said:

I remember hearing that patients don’t feel that they are having a complete exam unless their ears are checked. So I try to look in everyone’s ears. Takes me a minute at most, so why not?

Sounds good to me!

Happy holidays, all!

(H/T Drs. Sonja Solomon, Beret Amundson, and Mary Montgomery, all three of them graduate Chief Medical Residents, for helpful feedback on drafts of this post.)