How Much is Too Much During the Physical Exam?

With the evidence-based appraisal of the importance (or not) of routine physical exams, I am conflicted about what I am supposed to examine during the yearly “physical”.   Once upon a time, I did a head-to-toe exam on everyone. I labored under the adage that the only reason not to do a rectal exam is either because you had no finger or the patient had no rectum.

Today, the emergence of evidence-based guidelines suggest that routine screening examinations from a breast exam to a prostate exam are unlikely to reveal anything that will help reduce morbidity or mortality. I struggle with how much to do, when to do it, and whom I should be doing it on.

I thought about this during a recent physical exam on a middle-aged woman. As I perused her history, I wondered whether her post-hysterectomy status should dissuade me from doing a pelvic examination. I do a clinical breast exam yearly, even though I recognize it may not do anything except cause more diagnostic investigation. I’ve often wondered what the point of looking in an ear or nostril is when the patient has no increased risk of problems and no symptoms. 

As I conducted the physical examination on my patient, I noticed that she had a middle ear effusion. We spoke about it and she endorsed some ear discomfort and sinus symptoms. She left with a prescription for a nasal steroid and a suspected cause of her intermittent headaches. Looking in her ears was beneficial as it unearthed a symptom that she hadn’t endorsed on her review of systems and for which treatment may help.

However, I still struggle with the more uncomfortable examinations. Neither a rectal exam nor a pelvic examination is psychologically or physically comfortable. So, my tendency has been to omit these examinations if there is not a symptom I’m checking or a screening test I’m doing. Yet, I wonder if my patients ever leave my exam room wondering if they got their money’s worth. Could my diligent application of evidence-based guidelines and concern for the patient’s comfort be interpreted as carelessness, disinterest, or professional laziness?

I recognize the importance of touch in the exam room and rarely fail to conduct at least part of a physical examination on patients.  Yet, I’m unsure how much touch is required to offer reassurance to a patient that they were thoroughly evaluated. Do patients truly feel better by being told to completely undress, sit in a gown, and have every part of them poked and prodded? Is the therapeutic benefit to a complete examination enough to override the evidence-based lack of benefit for decreasing disease burden?

I don’t know. However, I find myself doing more and more rather than less and less, despite good evidence that checking my patients’ ears is unlikely to have any benefits. I suspect that what is missed in the studies is the positive impact of the conversation between doctor and patient during the examination when an “oh, by the way” is remembered or a question prompts further investigation. So, while it may be true that my ability to find a malignancy during a routine pelvic examination is virtually nil, there may yet be benefit to the patient.