Physical Diagnosis 101

A young medical student at George Washington University carefully inserts an otoscope into classmate Quynh Nguyen’s ear and pauses in surprise at what he sees--red and inflamed tissue, not the normal pink of a healthy outer ear.

“Um, I think you might have an ear infection,” he tells her.

She does, indeed, and that is an unexpected bonus of George Washington’s back-to-basics emphasis on the art of “physical diagnosis.” First-year medical students regularly practice on one another, mostly to learn what is normal in order to recognize what is not; only rarely do they actually hit the jackpot and find anything wrong.

Until recently, physical diagnosis was becoming something of a lost art as doctors relied increasingly on high-tech, high-cost instruments such as magnetic resonance imaging machines to tell them what was wrong with their patients.

“To some extent, we have gone overboard on tests,” says Dr. Robert Keimowitz, dean of George Washington’s medical school. “Sometimes having an MRI is essential, but you don’t do it on everyone with knee pain. The key is knowing--through better physical examination--when to do it.”

Medical educators everywhere are teaching their students to rely more on the less expensive diagnostic tools of yesteryear, and Keimowitz says the cost-cutting climate of managed care is a major motivating force.

“What we are seeing are the health plans saying: ‘We don’t want you ordering expensive tests when a good physical exam will do,’ ” Keimowitz says.

Other experts, however, point instead to the conviction of many mainstream physicians that today’s young doctors have abandoned or are losing the profession’s traditional skills.

“Most of the concern comes from more senior physicians saying that today’s whippersnappers don’t know how to do it the old-fashioned way,” says Dr. David A. Asch, a medical ethicist at the University of Pennsylvania.

“On the other hand, it’s probably also true that the more senior physicians aren’t much better,” he says. “It is merely the case that they practiced during a period when more objective tests were less available, [and so] their view simply wasn’t challenged.”

At the same time, Asch acknowledges that the cost-saving effects of physical diagnosis make it all the more attractive.

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Physical diagnosis came into full flower only in the 19th century, when physicians discarded their traditional diagnostic technique--observation at a distance--in favor of a hands-on approach to try to figure out what was wrong with their patients. Doctors learned by doing over and over again, a process that often taught them more about medicine than any textbook or lecture.

In those days, the most advanced pieces of equipment were instruments that are considered basic today: stethoscopes, ophthalmoscopes, otoscopes. Using them accurately required keen observational skills.

During their first year at George Washington, students begin learning physical diagnosis on one another. They are taught where to place the stethoscope and hear the steady, reassuring rhythm of a healthy heart.

In their second year they start going into the hospital to see patients. Having learned the rudiments during their first two years, every student is expected to know by the third year how to take a complete history and perform a thorough physical.

Keimowitz says that many experienced physicians believe today’s med students are slow or reluctant to develop these skills.

“Senior doctors who supervise them come back and often say: ‘They don’t have it quite right yet.’ There just doesn’t seem to be enough reinforcement, and we’re trying to improve that right now,” he says.

He is aiming toward testing medical students at the end of their third year on their ability to take a history and perform a physical exam.

“Students shouldn’t complete the program without passing that hurdle,” he says.

Just as third-year med students are not as good as first-year residents at performing physical diagnoses, Keimowitz says, “the first-year residents are not as good as the first-year residents of 20 years ago, in part because of this greater reliance on tests.”

Keimowitz tells a story about himself to illustrate the fragile and often complicated balance that must be struck between physical diagnosis and the ability to recognize when more objective diagnostic tests are needed.

“Last fall I had a high temperature of 102 degrees for four days, and I diagnosed myself as having the flu,” he says. “But I called my own personal physician. He insisted that I have an X-ray--because of the fever.

“It turns out, I had pneumonia. He would have missed it on a physical exam alone, because there are some pneumonias that you can’t hear just by listening to the lungs--and this was one of them. But every patient who has a high fever should not have an X-ray.”

The key is being “good enough to say, ‘This is a good lung exam, and I’m not going to do an X-ray,’ ” he says. “But many physicians today are not confident enough to make that judgment. They say: ‘I’m not good at this--I’m going to do an X-ray anyway.’ ”

When first-year med students meet every other Tuesday evening at the ambulatory care center of George Washington University Medical Center, they wear bathing suits or shorts and sports bras under their clothes. Each session centers on a different part of the body: for example, the heart and lungs, the abdomen (bowels, kidney, liver, spleen) or the head (eyes and ears).

Nguyen, a native of Vietnam who grew up in Irvine, says the focus is on the basics.

“We are being introduced to the fundamentals and getting a feel for what is normal,” she says.

Students are taught how to listen, how to interpret what they touch, and how to tap “to listen to the sounds” that the tap produces, such as the “sound of fluid or a hollow sound. It takes listening carefully, and it takes practice,” Nguyen says.

She says that the morning after the ear and eye lesson, she went to the student health center for antibiotics to treat her ear infection.

“My ear had been aching, and I had been ignoring it,” Nguyen says, laughing.

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The practice sessions began years ago as strictly men on men and women on women, then switched to mixed groups and have now shifted to some of each--students get their choice. While there is little controversy over listening to the heartbeat or examining an ear of a classmate, the anxiety level increases with more sensitive areas of the body.

First-year students, for example, do not learn rectal examinations because they do not want to practice on one another. Men and women students learn to perform pelvic and breast examinations on women professionals hired from the outside to serve as models.

“I tell the students that I know they are uncomfortable about these things, but they have to learn,” Keimowitz says. “They have to realize that if they are embarrassed and nervous about themselves, then they will be reluctant to do these exams on a patient.”

At the outset, Nguyen says, many students were not comfortable removing even some of their clothes.

“Everyone was just a little wary,” she recalls. “But it was a valuable experience. You realize you just have to get used to it, because it’s the only way you’re going to learn. Also, we’ve spent most of the past year together, and everyone is professional about it.”

Moreover, she adds, “we were reminded of how uncomfortable it can be as a patient, having someone examine us. It was important for us to be sympathetic and sensitive to our patients’ sense of modesty by properly draping them. I was reminded how important it is to address all of my patients’ concerns.”

She recognizes the importance of the sessions and says she hopes they will enable her to make better judgments when she begins her own practice.

“I think my confidence will come in time,” she says. “This is only my first year, and I’ve only just touched upon a small portion of what I’ll be learning. This field is a lifetime of learning; it is never-ending. I’ll always have to read up on new techniques, new drugs, new technology--and know when to use them.”