■ Safety of care:

Improving patient safety and reducing risks

What happened to the physical exam?

Over time, this critical part of the patient assessment can fall victim to system and practice pressures

A jar of tongue depressors

6 minutes

Published: June 2019 /
Revised: October 2021

The information in this article was correct at the time of publishing
19-11-E

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. But how you perform the physical exam, and how often you perform it, can change over time and become overly limited without you realizing the impact on patients.

In medical school, physicians are trained in the critical skills of patient assessment. However, when physicians enter independent practice, system and practice pressures can arise – such as high patient volumes, resource constraints, and rapidly advancing technology. These pressures can lead to concerns about performing physical examinations; for some physicians, these concerns might be amplified by worries about boundaries and personal safety.1

Tailoring physical exams can be appropriate as a physician’s clinical expertise develops, and in certain settings and clinical scenarios. However, if the physical examination is too focused, or omitted altogether, the opportunity to capture clinical data may be lost.

The absence of an appropriate history and physical exam to flesh out a differential diagnosis is a well-documented, prevailing cause of diagnostic error leading to patient harm.2,3 The literature consistently supports the use and value of the physical examination, even in an era of sophisticated diagnostic tools.2,4

A review of CMPA medico-legal cases reveals a persistent theme of inadequate assessment by physicians. In CMPA files closed between 2019 and 2020, slightly more than one-quarter (26%) 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. Each of these drivers is discussed below.

Physical exams in the virtual care era

When there is widespread adoption of virtual care technology in physicians’ medical practice, as seen during the COVID-19 pandemic, the potential exists for in-person physical examinations to become more limited or less frequent. Physicians should be aware of the limitations of virtual care and ensure patients are provided with the opportunity for in-person care when required by the standard of care. It is important to be familiar with the professional and regulatory requirements and guidelines that have been developed to assist physicians in determining when in-person examinations may be necessary.6

Time constraints

Sometimes in busy clinical settings, the performance of an adequate focused physical examination is deferred because of the time required. This problem can be 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 any physical examination (including a digital rectal examination) at the time of presentation, and follow-up by the family physician.

Limited space

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. They describe 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, they undergo 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, which is 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 patient with a history of chronic low back pain and alcohol use disorder presents to their family physician. They request a refill of acetaminophen/oxycodone for their back pain. The family physician notes that this visit is early for the refill, and the patient acknowledges that they have increased the use of their 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. They insist on an increase in the dose of their 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. However, inadequate assessment can 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 try to preserve these as consistently as possible, even when pressed for time.
  • Be aware of the limitations of virtual care and ensure patients are provided with the opportunity for in-person assessment, where appropriate.
  • Have a plan in place for accessing appropriate chaperones and private spaces for intimate physical examinations.
  • Be aware of cognitive biases potentially influencing your clinical decision-making.
  • When you document, reflect on the adequacy of the physical examination and differential diagnosis. Ensure all physical examinations are well-documented in the medical record.

References

  1. Canadian Medical Protective Association. Is it time to rethink your use of chaperones? Ottawa (CA): CMPA;2019 March.
  2. Verghese A, Charlton B, Kassirer JP et al. 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
  3. Clark BW, Derakhshan A, Desai SV. Diagnostic errors and the bedside clinical examination. Med Clin N Am. 2018:102;453-64
  4. Hedian HF, Greene JA, Niesses TM. The electronic health record and the clinical examination. Med Clin N Am. 2018:102;475-83
  5. 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.
  6. Canadian Medical Association. Virtual care playbook for Canadian physicians. Ottawa (CA): CMA;September 2021.

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.