I’ve often heard physicians say that “the history is 90% of the diagnosis.” In other words, they can usually determine the underlying cause of a patient’s problem just by listening to their account of how it evolved. The physical exam is merely to confirm the diagnosis, and is often cursory, limited, or ignored.
I believe that the physical exam is far more important than it seems – and I learned this during my recent oral medical specialty board examination. Although I have been sworn to secrecy regarding the content of the test questions, I will share an epiphany that I had during the exam.
The examiners’ job is to describe a patient and then ask the examinee what else she’d like to know and what she’d do next. With each description, I found myself struggling to visualize the patient – wishing I could see their face and hear their tone of their voice as they described their condition. I hadn’t realized that so much of my clinical judgement was based on laying eyes on a patient – I needed to see if they were in pain, if they were straining to breathe, if their skin was pasty or pale, if they were disconnected and potentially drug-seeking, if they were fidgety, if they were articulate, forgetful, or well-groomed. All of these subtle cues were gone. I was left staring at the examiner – who himself couldn’t describe the patient more fully because he was to stick to the script, reading verbatim from a prepared list of signs and symptoms. Read more »