Family Physicians' Experiences of Physical Examination

Martina Ann Kelly, MA, MBBCh, FRCGP, CCFP; Lisa Kathryn Freeman, BSc (Hon), MD, CCFP, MPH, FRCPC; Tim Dornan, MA, DM, FRCP, MHPE, PhD

Disclosures

Ann Fam Med. 2019;17(4):304-310. 

In This Article

Abstract and Introduction

Abstract

Purpose: The increased availability of reliable diagnostic technologies has stimulated debate about the utility of physical examination in contemporary clinical practice. To reappraise its utility, we explored family physicians' experiences.

Methods: Guided by principles of phenomenology, we conducted in-depth qualitative interviews exploring 16 family physicians' experiences of conducting physical examination: 7 (44%) men and 9 women (56%) whose clinical experience varied widely, from 11 (69%) urban and 5 (31%) rural locations. We recorded the interviews, transcribed them verbatim, and identified initial themes using template analysis. We worked reflexively, critiquing our own and other team members' interpretations, in order to synthesize and write a final interpretation.

Results: Participants described 2 facets of physical examination: making diagnoses and estimating prognoses rationally and objectively; and responding subjectively and intuitively to patients' illnesses, which formed relationships between doctor and patient that enacted medical care in the moment. Physical examination allowed physicians to use their own bodies to experience patients' illnesses. Performing physical examination was integral to being a family doctor because it promoted rapport and developed trust.

Conclusions: Physical examination is part of the identity of family physicians. It not only contributes diagnostic information but is a therapeutic intervention in and of itself. Physical examination contributes to relationship-centered care in family practice.

Introduction

The role of physical examination in contemporary medicine is debated[1–4] because clinical skills, like other aspects of practice, are being scrutinized for supporting evidence. Critics draw attention to the low diagnostic accuracy of physical examination[4] and ask whether it is an outdated practice. As technology has gained ground and graduates have questioned the utility of physical examination,[5] they have become progressively less confident about performing it.[6,7] Meanwhile, proponents argue that graduates' declining physical examination skills are increasing health care costs by making misdiagnosis more likely.[8–10] This impasse calls for a deeper examination of how physical examination can contribute to family practice.

The debate about whether physical examination should be taught and how it can contribute to practice has taken place in the rational and objective territory of clinical decision making.[11–13] Here, physicians are neutral interrogators of patients' passive bodies. But physicians also practice subjectively. Advocates for physical examination argue that it is a cornerstone of medicine, a privileged human interaction[14] within an age-old tradition of laying on hands. It is a symbolic enactment of healing, which expresses the fundamental humanity of doctor-patient relationships.[15] In support of this perspective, the experiences of both patients[16,17] and physicians[18] suggest that physical examination serves a healing purpose as well as a diagnostic one. These narratives describe how the subtle exchange of a glance or an unexpected tactile sensation led to a revelatory insight that formed a bond between a patient and a physician. According to these accounts, physical interactions are entry points to existential engagements between patients and physicians. Research into physicians' subjective experiences is fragmentary and limited, however.[19,20]

We reasoned that the debate about physical examination would be more balanced if we articulated valid, subjective reasons for performing it. This led to the research question: "What are family physicians' experiences of performing physical examination?"

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