Bedside Medicine: Why It's Still Vital, to Patients and Physicians

Gabriel Miller


December 12, 2017

Editor's Note:
This interview with John Kugler, MD, a specialist in physical exam skills and bedside medicine, was conducted at the Stanford25 Skills Symposium, an annual program that focuses on bedside medicine at Stanford University School of Medicine. It has been edited for length and clarity.

John Kugler, MD, demonstrates his handheld ultrasound technique at the Stanford25 Skills Symposium at Stanford University.

Medscape: You've written previously about the history of the bedside exam and the way it's been represented in textbooks and medical literature. In your words, what is the state of the bedside exam right now, looking at it historically?

Dr Kugler: The state of the bedside exam is really in peril. If you asked a substantial number of practicing physicians, they would tell you, "You know, I can make most of my decisions without even seeing the patient. I can be like the guy in a control tower. I'm getting my information feed, and I'm clicking the right buttons to make the right decisions to make the patient better."

There's a real worry there. If you ask people around Silicon Valley, they say, "We're going to replace doctors with artificial intelligence." That's that same thing—there's the box that's taking in the data and spitting out the answers. That's the view of what the physicians do: We're the information processor who spits out the answers.

"For those of us who've been patients, that's not necessarily what we want."

For those of us who take care of patients, and for those of us who've been patients, that's not necessarily what we want. It's a nice vision in some ways, but it's not really what we want. We want to trust the person sitting across from us. We want to rely on their experience and where they've been rather than on a mathematical formula. We want them to understand what our values are.

I'm very worried that people are not respecting the importance of the bedside exam. Somehow, we have decided to value less what we find at the bedside and value more what we find on a computer. Patients are full of nuance, and that makes it harder. The computer is black and white, and that's easier. I understand the temptation, and I'm sure I've fallen prey to that temptation. But I think we need to come back to the beside and do the harder thing—it's the right thing.

Medscape: A couple of years ago, you wrote a paper that rather provocatively characterized the physical exam as a fiction, specifically with respect to the electronic health record (EHR). What did you mean by that?

Dr Kugler: This is an epidemic. There's no way around it. And you can talk to any physician who would say, "Oh, I've seen this."

What you're often documenting [in EHRs] is for billing purposes. What that often requires is for you to document a very full physical exam. The challenge is that exam is not necessarily always being done, but the default is for [the EHR] to say that it has been done. That's dishonest, and in truth it passes along false information.

And you see such things as an exam that's cut and pasted from the previous day for inpatients. So, there will be a patient who left the intensive care unit 5 days ago, and the exam is still documenting that the endotracheal tube is in place. It's clearly not been in place for 5 days, but it still seems to be there. Even if the exam was done and done well once, it's not even being updated.

I don't want to say that the exam is not being done at all, but way more is being documented than is being done. That's a problem.

Personally, I'm not sure that paying physicians more on the basis of doing things they don't need to do is the right thing. If the physician at the bedside thinks the only things that need to be examined are three specific things, why do we incentivize them to document that they've examined 12 things, when the way they structure their practice, and their years of experience, say they need to examine only these three things? We're encouraging them to say, no, you've got to do a 10-point physical exam, regardless of its appropriateness.

We have a misalignment of incentives that encourages physicians to document things that weren't done. It's a real challenge, and it should really stop.

"Way more is being documented than is being done. That's a problem."

Medscape: What do you see as some of the biggest barriers to teaching physical diagnosis to trainees, whether they be students, residents, or fellows—the next generation?

Dr Kugler: Everyone is more pressed for time, partly because they're spending more time on EHR. But there are some cultural issues as well. Part of it is the reliance on technology—looking for labs. Dealing with nuance is hard. Trainees want something that's black and white: "Sodium is this, therefore that." They want it to be very clear-cut, as we all do. It makes things easier.

I think probably the biggest barrier ends up being cultural. I can take my students, and I do, and teach them about physical diagnosis, and do bedside rounds. But the challenge is, who do they really learn from? Hopefully they learn some from me, but in their day-to-day work, they're spending 10 hours a day with the house staff. They're going to maybe spend 45 minutes of the day with me.

Unless we can reach out to house staff and change the way they practice, it just trickles down. We need to change that culture, because it flows from them.

As we start to lose respect for the physical exam, it very quickly can diminish. As I started to say, it's hard. It's much easier to learn how to interpret a piece of lab data than it is to interpret a physical exam. So, it's not easy to do, and it takes time. If you have a young generation of clinicians who don't have the skills, that's how they're going to practice, and that's now what they're going to teach. It's something that is difficult to maintain.

Medscape: Bedside ultrasound is a passion of yours. In medicine, I frequently encounter evangelists for this technology. What potential do you see for handheld ultrasound improving the bedside exam?

Dr Kugler: I love that you use the term "evangelist," because I often tell people that I am definitely not an evangelist for ultrasound. You will run into people who will more or less say, "I can't see a patient without an ultrasound." That's crazy. I want to say, that is not true. This is a great technique, and it does help me to take better care of my patients, but too often it can become polarizing. There's one group saying, this is the greatest thing ever and if you're not doing it, you're not a good doctor. Then, the other people are saying, you're wrong and I'm not doing it. We need to be much more in the middle when we think about this skill.

So, I really try to avoid being an evangelist, and, as much as I can, be a realist. This is an important technology, and it is going to be part of the future, but we can't forget the really important knowledge we've learned over the past 100 years. We need to be honest when we ask how much better bedside ultrasound is at figuring out certain things compared with the physical exam or chest radiography. We need to be really careful and not oversell the technology.

When I'm teaching this to our residents, I spend most of my time saying, "Okay, you've got the picture. Now, incorporate it into your physical exam. What didn't fit with your physical exam, and what are you going to do to sort that out?" Rather than saying, "Well, I saw it on the picture; that means it must be true."

"The technology is so seductive."

I think a lot of the ultrasound naysayers have been burned by that before. They've had a resident who gave the wrong treatment because they trusted only what they saw on the screen and didn't take a look at the rest of the patient.

So, I think those of us who want this technology to happen have to be careful. We have to be careful that people are well trained. We have to be careful that they understand the limitations. We have to be careful that they integrate this in to what they do, and not just rely on it alone. That's what I worry about—[trainees saying] "I don't need to learn how to listen to the lungs. I don't need to learn to listen to the heart. I don't need to notice the jugular venous pressure, because I've got my ultrasound." You still need to do all those things and do the ultrasound. It's not an either/or. I spend a lot of time trying to drum that message into the residents, because the technology is so seductive.

Medscape: One of the most interesting aspects is that it's imaging, but it's with the patient. They can see it [alongside the physician]. That in itself is a bedside moment. Are there other technologies that you're aware of that have that potential?

Dr Kugler: Everyone, when they talk about the EHR, talks about how terrible it is. "It's ruining things. It's annoying. I click all day." But it doesn't have to always be annoying. In fact, there's some real value there.

One of the things I love to do with my patients is they'll say, "Hey, doc, what did my chest x-ray show?" Rather than trying to describe it to them, I say, "We can look at it together right now." I have access to the EHR, and they all have image viewers in them, so I pull it up, and then I show them their chest x-ray and point to it.

When I'm sitting there with a patient and come up with a plan, one of the things I love to do is tell them, "I'm going to do that right now." Then, I put the plan into the EHR. They don't have to trust that you're going to remember to do it—they're seeing you do it. They're seeing you put in that work. Why go back and do that work remotely from them, when you can do it right then? And then, when they think of another question to ask you, you're still sitting there. You don't have to get paged by the nurse.

In my mind, the EHR is not all bad. There are so many wonderful things about it. For those physicians out there who are old enough to remember searching for the vital signs charts and figuring out who lost that [document], or trying to decipher a physician's handwriting that you can't read, [the EHR] has solved a ton of problems.

And if we use it right, it can become a bedside tool. I love doing that for patients, showing them their images or their labs. In the future, they're going to be getting their labs. They're going to be sitting there, and I'm going to walk in, and they're going to tell me, "Doc, my sodium is down to 130. What does that mean?" They're already going to know [the labs] even before I walk in. I welcome that. I think that's going to be a great tool. It's a conversation starter. You have the data; I have the data; let's talk about it.

Medscape: When I talk to physicians who are interested in bedside medicine, almost universally they feel that physical exam skills are decreasing. As someone who teaches beside medicine specifically, do you see any possibility of reversing this trend? If so, where does your hope lie to accomplish this?

Dr Kugler: The funny thing, is you can go back through the literature and find that the worry that physical exam skills are decreasing certainly goes back to at least the 1970s. That's the earliest paper I could find, but I bet if you kept looking, you could find papers from the 1940s and 1950s that would say the same thing. It's been a continued worry.

But more and more, I don't think it's a completely made-up trend. I do really think it is a problem. We need to get back to the bedside and spend more time there. There's no question that we need to do the right exam and document it correctly.

In terms of reversing the trend, I don't know whether it's 5 years from now or 10 years from now, but I think that artificial intelligence and big data are going to affect medicine. I think they're going to help a lot with decision support—take away a little bit of what has been the physician's role for a long time, which is data analyzer. Instead, the physician is going to have an even more important role of inputting data. My physical exam is going to become even more important, because a computer is not going to be able to do a good physical exam, but I can. So, I think my information gathering is going to be even more important.

Then, the value of the communication, the interpersonal skills, the human skills that I bring to the beside is going to go up. Too often, our students, when they're learning about medicine, think the most important thing they do is make a decision. I almost have to get them to unlearn that. Actually, the harder thing is to figure out, together with the patient, what the right decision is. I'm not sure how to teach a computer how to do that.

"The machine learning age is actually going to refocus us on our human skills."

So, when I think about the future of bedside medicine, I think that the computer age, and really the machine-learning age, is actually going to refocus us on our human skills. Part of that is going to be our physical exam skills. But it will also be our communication skills, our presence at the bedside. We're going to be forced to refocus on that, because that's so much of the value that we bring as people. As they work out better algorithms, machines are going to beat us—but they're not going to beat us at the bedside. I don't foresee that in any time horizon. People are going to connect better with other people.

Medscape: Do you see the physical exam as a way to potentially mitigate, or reverse, physician dysphoria and physician burnout?

Dr Kugler: I do think that if you're sitting down with a physician who wants to argue that they don't need to do a good exam, they can [indeed] practice without doing it. Or, [they may say] "Show me the evidence that it changes outcomes." I think there's some evidence there. And people are always saying, "Well, does it save money?" No. We could use better evidence there.

"Feeling that you can figure something out at the bedside provides a huge amount of professional satisfaction."

But I've decided that two things for which the bedside exam is almost certainly the most important are the physician-patient relationship and physician satisfaction. Feeling that you have a degree of expertise—that you don't need to get a million tests or call a specialist, but you can figure something out at the bedside—provides a huge amount of professional satisfaction.

If I listen to your heart and I'm pretty sure that [I hear] aortic stenosis, I'm still going to order the echocardiogram. It's not necessarily going to change what I do in that moment. But, to me, I get a lot of satisfaction [from the feeling that] my exam was right on. It makes me feel like I have the expertise that I need to take care of patients. So, even beyond cost savings, beyond diagnostic accuracy, physician-patient trust and professional satisfaction are huge drivers to develop these skills.


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