Physicians Are Talking About…

The Basics Versus Technology: Which Wins?

Brandon Cohen

Disclosures

April 09, 2018

A recent article featured a discussion between Drs Charles P. Vega and Fabrizia Faustinella in which they posed the provocative question of whether doctors had gotten lazy, particularly when it came to performing hands-on physical exams. They described what they saw as deteriorating abilities among colleagues and residents when it came to the basics of examining patients. This spurred a robust discussion by readers about the issue.

Many physicians objected in particular to the use of the word "lazy" in the title. One internist employed sarcasm: "Yes, let's keep supporting doctor-bashing, the new sport; It might make it to the Olympics."

But others saw necessary criticism in the article:

It's not doctor-bashing; it is today's reality. I truly believe that to many young doctors, the actual laying of hands is considered a nuisance. Much easier to order expensive tests and scans. Clinical judgement is now ridiculed because it doesn't stand up in court like an MRI does. Sad but true. But it's not just young doctors; the surrounding healthcare team doesn't trust clinical acumen anymore. One of the main reasons I quit inpatient pediatrics over a decade ago.

An internist agreed:

I have noticed exactly this phenomenon as the modern practice model becomes more and more monetized. Insistence on a good history and physical is extremely difficult to sustain. It is entirely unsupported within the system; and, frankly, physicians who attempt to maintain the integrity of a good history and exam in spite of practice pressures end up heading toward burnout.

But a pain management specialist was not convinced:

So based on a couple of anecdotes involving residents, the doctors determine that there is a consensus that physical exam skills are deteriorating.... Most of the physicians I know work at least 50 hours per week in direct patient care plus another 10+ in nuisance paperwork. I don't see a trend toward laziness here.

An internist even went after Dr Faustinella, who had mentioned some basic errors made by her residents:

Your residents were negligent in not examining a patient with the light on. If you run that department, that's on you. Residents are under your supervision. Lay off the rest of us.

Another response offered the perspective of a nurse practitioner:

[Electronic health records] certainly put a real barrier between the physician or nurse and the patient. One of the effects of this barrier is the loss of eye contact with a patient and observance of their facial and body expressions.... I used to note whether or not a patient exhibited a positive toe curl sign when I was examining their abdomen, in particular. Often even a stoic patient doesn't control this sign of pain or discomfort, and this can lead to further appropriate questioning.

An obstetrician/gynecologist shared these concerns but felt that there was no fighting modern trends:

Your concerns are well placed, but I believe there is no going back. We will have to continue to use enhanced technology to manage clinical problems. For example, new and improved ways of screening our populations to select those for specialized testing will be developed. The algorithms will improve over time so that fewer patients will fall between two [distinct decision points], and further novel algorithms will await those who do. Thorough and meaningful clinical bedside examination will be doomed to the history books. It is too cumbersome and inefficient for modern medical needs. Bit by bit, each component will be replaced by technological progress.

But a psychiatrist thought this was going too far:

Technology provides us the additional edge—additional to what is basic. It is not meant to replace the basic.

An internist sought to highlight one of the causes of this apparent laziness:

Doctors often overschedule themselves.... One might be able to squeak out in 20 minutes the same visit that takes another physician 30 minutes and charge the same amount, but...habitually cutting corners to increase one's productivity is unfair—to patients, to those who are paying higher insurance rates due to the inefficient costs of care, to those who really do need the expensive testing but can't [get it] due to restrictions placed in part due to sloppy ordering by others, and to colleagues who are making the sacrifice of time needed to do things in proper order.... If we want to change the culture, there will need to be a realistic view of time demands placed on residents. When there is a delay due to the need to do an honest job at the expense of appearances, it should be recognized as such.

A primary care physician looked beyond shoddy exams to potential deceptions:

It causes me great distress to see the disparity between what is actually done on physical exam as opposed to what is documented. I'm afraid residents now are increasingly taught what they need to do to justify a particular level of service.

Another primary care physician drew on personal experience as a patient:

I'm frequently embarrassed for my colleagues who pretend they're listening to my heart and lungs...as they make a stab at moving the stethoscope over the paper gown.... I know what they're hearing: crunch, crunch.

The final word goes to a radiologist who offered an international perspective:

I trained in Ireland in the 1960s.... There was a heavy reliance on history and physical. When I came to the USA in 1968 and did not order a lab test as it was not necessary, I was accused of laziness.

The full discussion of this topic is available at Are Physicians--Let's Face It--Getting Clinically Lazy?

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