Over time, this critical part of the patient assessment can fall victim to system and practice pressures
Originally published June 2019
The physical examination is a powerful tool in the physician’s diagnostic toolkit. Performed effectively, it can improve the accuracy of your diagnoses and help avoid harm to patients. Yet, how you perform the physical exam can change over time and become overly limited without you realizing the impact on your patients.
In medical school, all physicians are trained in the critical skills of patient assessment. However, when you enter the world of independent practice, system and practice pressures are quickly brought to bear, pressures such as high patient volumes, rapidly advancing technology, and complex systems. These pressures can lead to concerns with performing examinations including, for some physicians, concerns with boundary issues.1
Commonly among trainees and experienced physicians, the physical examination becomes more tailored over time. This can be appropriate as clinical expertise develops and in certain settings and clinical scenarios. But sometimes, if the physical examination is too focused or omitted altogether, the opportunity to capture critical clinical data to develop a differential diagnosis is lost and the patient may be put at increased risk of harm.
One well-documented, prevailing cause of diagnostic error leading to patient harm is the absence of an appropriate history and physical to flesh out the differential diagnosis.2, 3 Often due to competing demands for your time, it can be hard to pause and reflect on the implications of limiting the physical examination for an individual patient or even more systematically for groups of patients. The literature consistently supports the use and value of the physical examination, even in this day and age of sophisticated diagnostic tools.2, 4 Clinical correlation remains essential since no single diagnostic test has 100% sensitivity and specificity.
CMPA medical-legal cases display a prominent theme of inadequate assessment by physicians. In the CMPA’s files that closed between 2016 and 2017, almost one-quarter of civil legal cases and regulatory authority (College) complaints contained peer expert5 criticism of issues related to patient evaluation. When examining these cases more closely, three key drivers emerge: a lack of time, a lack of physical space, and the presence of cognitive biases.
Sometimes in busy clinical settings, the performance of an adequate focused physical examination is deferred because of the time required. This is often compounded by the need for chaperones for intimate examinations.1 Consider the following case example.
Case example: A lack of digital rectal examination leads to diagnostic delay
In the middle of a compressed clinic day, a family physician assesses a new patient with a history of diverticulitis who presents with new onset of increasingly frequent stools with occasional blood. The family physician orders stool specimens for ova and parasites, and culture and sensitivity. The patient returns 3 weeks later with ongoing symptoms. The family physician notes normal culture results and refers the patient to a gastroenterologist. Two months later, the patient has yet to see the specialist and presents to the emergency department with frank blood and low hemoglobin. During admission to hospital, a colonoscopy reveals a large rectosigmoid tumour, palpable at the anal verge. The patient launches a College complaint alleging a delayed diagnosis. The College committee is critical of a lack of consideration of the differential diagnosis, documentation of the physical examination (including a digital rectal examination) at the time of presentation, and follow-up by the family physician.
In addition to time constraints and the need for chaperones, the extent of a physical exam can be affected by space limitations as illustrated by the following case example.
Case example: Space restrictions lead to a missed time-sensitive diagnosis
A 12-year-old boy presents to his local emergency department by ambulance at 2000h on a long weekend, when the department is experiencing very high volumes. He describes lower abdominal pain, nausea, and vomiting. Due to crowded conditions in the emergency department, the child is placed on a hallway stretcher. The emergency physician assesses and examines the child, noting the abdomen is soft and non-tender. The physician orders bloodwork, urinalysis, analgesia, and an antiemetic, but does not perform a genital examination because the patient is not in a private area. Following normal investigations and improved symptoms, the physician discharges the patient at 0200h. The patient returns the next day at 1600h with a painful and swollen testicle. An ultrasound confirms testicular torsion, and within 2 hours of presentation, he undergoes an emergency orchiectomy. In the ensuing legal action, peer experts opine that it was the emergency physician’s responsibility at the initial visit to find a private room to conduct the appropriate examination for this time-sensitive condition, which was an important part of the differential diagnosis.
Presence of cognitive biases
All physicians are susceptible to cognitive biases, including when making clinical decisions to form diagnoses. At times, you will manage patients exhibiting challenging behaviours, which may increase your susceptibility to sub-optimal clinical decision-making. In the following case example, a diagnosis was missed due to attribution bias, the tendency of physicians to explain a patient’s condition on the basis of their disposition or character, rather than seeking a valid medical explanation.
Case example: The diagnostic process is confounded by attribution bias
A 40-year-old woman with a history of chronic low back pain and alcohol use disorder presents to her family physician. She requests a refill of acetaminophen/oxycodone for her back pain. The family physician notes that this visit is early for the refill, and the patient acknowledges that she has increased the use of her prescribed analgesic due to a recent knee injury. The family physician provides the refill. Four days later, the patient returns complaining of headache, nausea, abdominal distension, and decreased voiding. She insists on an increase in the dose of her acetaminophen/oxycodone. Feeling frustrated with the patient’s confrontational behaviour, the family physician attributes the symptoms to alcohol and opioid withdrawal without further evaluation and declines to renew the prescription. The next day, the patient presents to a local emergency department with acute liver and kidney injury secondary to acetaminophen toxicity. The patient complains to the College. During the College investigation, peer experts criticize the lack of a documented physical examination at both visits to the family medicine clinic, particularly with the onset of new symptoms.
The bottom line
The physical examination remains a powerful tool in your diagnostic toolkit. There are many reasons why an examination may be incomplete or not adequately performed. Inadequate assessment can, however, negatively affect the accuracy of diagnosis and safety of medical care.
Consider the following when aiming to reduce your medical-legal risk:
- Engage in reflective practice. Consider what parts of the physical examination are critical for different patient groups and contexts and be mindful to preserve these as consistently as possible, even when pressed for time.
- Have a plan in place for accessing the appropriateness of chaperones and private spaces for intimate physical examinations.
- Be mindful of cognitive biases potentially influencing your clinical decision-making.
- Use the act of documenting in the medical record as an opportunity to reflect on the adequacy of the physical examination and differential diagnosis.
- Canadian Medical Protective Association [Internet]. Is it time to rethink your use of chaperones? Ottawa (CA):CMPA;2019 March [cited 2019 March 20]. Available from: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2019/is-it-time-to-rethink-your-use-of-chaperones
- Verghese A, Charlton B, Kassirer JP, Ramsey M, Ioannidis JP. Inadequacies of physical examination as a cause of medical errors and adverse events: A collection of vignettes. Am J Med. 2015;128(12);1322-1324
- Clark BW, Derakhshan A, Desai SV. Diagnostic Errors and the Bedside Clinical Examination. Med Clin N Am. 2018:102;453-64
- Hedian HF, Greene JA, Niesses TM. The electronic health record and the clinical examination. Med Clin N Am. 2018:102;475-83
- Peer experts refer to physicians retained by the parties in a legal action to interpret and provide their opinion on clinical, scientific, or technical issues surrounding the care provided.