Opinion
A PIECE OF MY The Quick Physical Exam
MIND
Robert E. Hirschtick, The intern presented a case of an elderly woman
MD admitted for evaluation of chest pain. Serial ECGs and
Department of troponin levels were normal, and the diagnosis
Medicine,
remained obscure. I began my cardiopulmonary exami-
Northwestern
University, Chicago, nation by partially lowering her hospital gown. It imme-
Illinois. diately became apparent that she had a dermatomal
vesicular rash of herpes zoster. The resident, intern,
and student all sheepishly admitted they had auscul-
tated the patient’s heart through her hospital gown.
They had performed the quick physical exam.
I cringe every time I hear the phrase “quick physical
exam” on the wards of our teaching hospital, which is
often. The phrase is especially cringe-worthy when
consent is sought, ie, “May we do a quick physical
exam?” I have several problems with this question,
related to what the questioner means and what the
patient hears. Is the questioner seeking consent to per-
form an examination, to perform it quickly, or both? It
seems to me that consent for examination is implied in
the hospital setting and asking permission unnecessary.
Soliciting permission for quickness is more problematic.
I believe the solicitor means “We don't wish to inconve-
nience you by taking up too much of your time.” This
misses the point that inpatients are already greatly
inconvenienced by virtue of being inpatients. Rather
than inconvenient, a careful physical examination,
especially one that might shorten the hospital stay,
would be welcomed.
Woe to the patient who consents to the quick physi-
cal exam. The four pillars of physical examination—
observation, percussion, palpation, and auscultation—
are reduced to the latter two, both shaky. One team
member palpates the abdomen while another asks fur-
ther history questions, thus rendering the patient’s
facial expressions inscrutable. Pupils are equally round-
about and reactively accommodated to time con-
straints. Auscultation is particularly convoluted. Three
stethoscopes are applied simultaneously to the
thorax—okay over the vast expanse of the posterior
chest wall but chaotic at the precordium. To reduce
the risk of volvulus, a standardized rotation is used,
ie, stethoscope No. 1 starts at position No. 1 (right upper
sternal border), stethoscope No. 2 at position 2 (left
upper sternal border), and so on. Positions rotate every
two seconds. A well-oiled team can complete the quick
physical exam with the speed of a NASCAR pit crew. All
this hubbub suggests a less charitable motive for seek-
ing consent in the first place. Perhaps the seeker, per-
ceiving the physical exam to be unhelpful, is at some
Corresponding level hoping the patient will say no so that the nasty
Author: Robert E. business can be avoided altogether.
Hirschtick, MD (rober
I recently witnessed a physical examination deftly
@northwestern.edu).
avoided. The patient had tachycardia related to atrial fi-
Section Editor:
Roxanne K. Young, brillation, and our medical team was trying to control the
Associate Senior Editor. heart rate while avoiding hypotension. I asked the in-
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tern to check the pulse while I measured the blood pres-
sure. Here was an opportunity for the intern to use his
fingertips to measure heart rate and assess perfusion
while also reassuring the patient through the intimacy
of physical contact. Without hesitation, the intern in-
stead placed a pulse oximeter on the patient’s finger. I
was aghast. Given a choice between touching the pa-
tient and using a mechanical device, the intern chose the
device, in this instance, a device nonsuperior to physi-
cal examination. When I asked him why, his response was
eloquent in its brevity: “Why not?”
As I am casting stones at my younger colleagues, it
should be pointed out that I am not without sin in this
regard. A patient was recently admitted to our service
with severe left thigh pain. Examination of his hip and
thigh was unrevealing except for increased pain with hip
extension. CT imaging of his pelvis and retroperito-
neum showed a prostatic abscess. The subsequent
physical examination by the urology consultant re-
vealed left epididymitis—a key examination finding
that I had missed. I had examined the patient’s area of
concern adequately enough but not the adjacent neigh-
borhood. This omission resulted in a delay in therapy and
is consistent with a recent physician survey of physical
examination errors.1 The most common error—63% of
all cases—was failure to perform an appropriate physi-
cal examination, compared with 25% of cases in which
the physical examination was performed but an impor-
tant finding was either missed or misinterpreted. These
physical examination errors resulted in significant con-
sequences—the proper diagnosis was either delayed or
missed in three-quarters of cases.
Patients, of course, are on the receiving end of the
quick physical exam. What do they hear when they
hear “quick physical exam”? I suspect “quick” is not
heard as “for your convenience,” but rather “cursory.” It
cannot be very reassuring to hear one’s physician ask
permission to be cursory. Verghese2 reminds us that
when performed well, the physical examination “sug-
gests attentiveness and inspires confidence in the phy-
sician.” Not so the quick physical exam—it suggests
carelessness and inspires skepticism.
Physicians, for their part, may indeed intend
“quick” to mean “cursory,” not because they are lazy,
but because they lack faith in the physical examination,
viewing it as a quaint but low-yield relic of a bygone
age. This view is mistaken. Despite the tyranny of
imaging, there remains great diagnostic value in the
physical examination. Reilly3 described 26 instances in
100 consecutive inpatients in which an unhurried
physical examination yielded pivotal findings that led to
a change in diagnosis or management. In contrast, the
quick physical exam is low-yield and, in self-fulfilling
fashion, confirms its lack of worth in the minds of both
examiner and patient.
(Reprinted) JAMA October 4, 2016 Volume 316, Number 13 1363
 Opinion A Piece of My Mind

Perhaps the bar for physical examination skills has been set too
high. Collectively devoting less time and consideration to the physi-
cal examination has elevated it into a mystical realm, with exper-
tise possessed by only a select few. Trainees react to Verghese’s
physical examination demonstrations as if he “were performing
magic.” This reaction is common among Sherlock Holmes aficiona-
dos. My desire to emulate Holmes at the bedside is tempered by the
knowledge that I will always fall short. My ego is assuaged, how-
ever, by the fact that Holmes is fiction. Arthur Conan Doyle already
knew “whodunit” before Holmes ever physically examined a crime
scene. Yet the Holmes fiction contains an important fact about the
value of focused observation: “The world is full of obvious things
which nobody by any chance ever observes.”4 It is not chance but
diligence that fuels Holmes’ work, and certainly Doyle, trained as a
physician, appreciated the value of a careful examination. Few of us
can be like Holmes—or even Verghese or Reilly, for that matter—
but all of us can be better observers and data gatherers at the bed-
side. In this regard, it is the attentive Dr Watson who serves as the
better role model—not the buffoonish Nigel Bruce of the RKO era,
but the attentive Lucy Liu and Martin Freeman of the Roku era.
Those of us who are role models can do better. I regularly
take students to the bedside to review physical examination find-
ings. These are bright, motivated students who want to learn
examination skills but consider proficiency beyond their reach.
For example, students often say that any murmur they hear is at
least grade 2 because they lack the skill to hear a grade 1 murmur.
Poppycock! It doesn’t require skill to hear a soft murmur; it
requires several moments of quiet concentration. Perhaps mov-
ing the physical examination from its natural place in morning
rounds to a special afternoon session reinforces the fallacy that
physical examination skills are special skills to be performed by a
specialist. As a role model, I can do more good by demonstrating
a thoughtful physical examination during morning rounds, time
constraints be damned.
As clinicians, we must agree to agree that there is worth in a
carefully performed physical examination. Unlike the quick physi-
cal exam, which yields only expected findings, a thoughtful physi-
cal examination often yields unexpected findings—pivotal data
that can lead to timelier diagnoses and fewer tests. My advice to
clinicians seeking to improve their physical examination: Think
Nike—just do it. Don’t aim for Holmes’ expertise; aim for Watson’s
competence. Be vigilant for readily accessible clues—orthostatic
hypotension and jugular venous distention were among Reilly’s
pivotal examination findings. Insist that your role models role
model. Lower the patient’s gown. Use your fingertips. And don't
be quick about it.

Conflict of Interest Disclosures: The author has
completed and submitted the ICMJE Form for the
Disclosure of Potential Conflicts of Interest and
none were reported.
Additional Contributions: I am grateful to Carol
Hirschtick for her thoughtful critique of this essay.
1. Verghese A, Charlton B, Kassirer JP, Ramsey M,
Ioannidis JPA. Inadequacies of physical examination
as a cause of medical errors and adverse events:
a collection of vignettes. Am J Med. 2015;128(12):
1322-4.e3. doi:10.1016/j.amjmed.2015.06.004
2. Verghese A. Culture shock—patient as icon, icon
as patient. N Engl J Med. 2008;359(26):2748-2751.
doi:1056/nejmp0807461
3. Reilly BM. Physical examination in the care of
medical inpatients: an observational study. Lancet.
2003;362(9390):1100-1105.
4. Doyle AC. The Hound of the Baskervilles. Dublin,
Ireland: Roads Publishing; 2013.

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