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

Findings

Sixteen family physicians participated. Nine participants were women, and 11 worked in urban practice (Table 2). They described a wide range of experiences, such as periodic health examinations, examinations for acute illness (sore throat, acute abdomen, fractures), and finding both the normal and the abnormal or unexpected.

Two Greek words (gnostic and pathic), used by phenomenologists to distinguish contrasting facets of human experience,[22,36] summarize the main findings. These words are more familiar to physicians than they may first appear. The objective and rational facet of physical examination served gnostic purposes: diagnostic and prognostic. But that was not physical examination's only purpose. Its pathic facet served tacit, deeply subjective purposes in doctors' relationships with patients; physical examination could also be empathic. The words gnostic and pathic are so deeply embedded in medical language[37] and philosophy, and so clearly describe 2 complementary facets of practice, that we use them despite their relative unfamiliarity. We first present evidence to support the distinction between gnostic and pathic experience and then describe 4 subtypes of pathic experience: experiencing through relationship, experiencing through doing, experiencing through time, and experiencing through the body.

Physical examination was an embodied part of participants' practice, part of being a physician.

"A doctor who did not examine patients was not a "good doctor," "because that's about connection and relationship and if you don't have that, I don't care how good a doctor you are, you are not a good doctor. … [It's] specific to being a physician. So that part is special. That's mine." (participant 9, female, urban practice, >20 years' experience)"

Physical Examination as Gnostic

Physical examination was intellectual and rational. It confirmed or refuted working hypotheses generated by the history. "I use physical exam to confirm what I'm looking for in the history, rule out what I'm looking to rule out. Rarely is there an absolute surprise but I don't want to miss it" (participant 2, female, urban practice, >20 years' experience). It helped participants rise to the intellectual challenge of physical diagnosis. "I felt like I had a clue and I wanted to pursue it" (participant 4, male, urban academic practice, >20 years' experience). "Old-school" or "old-fashioned" physical examination had to be thorough, so as not to "miss something." Occasional experiences of finding the unexpected reinforced participants' habit of examining patients: "I find something completely new or unrelated that I might not have seen, you know, there's a reason we call them incidentalomas, so I think it's always worth doing that exam" (participant 3, male, locum, urban practice, <5 years' experience). Although history taking was fundamental to making diagnoses, consultations that included physical examination felt more complete.

Physical Examination as Pathic

Physical examination also had a subtle facet, whose essence was in the subjective and social interaction between patient and doctor. Physical examination was integral to participants' relationships with patients: even when it was not "clinically necessary," the doctor or patient might expect it. Fulfilling the expectation built the relationship between them.

"I think you do make a connection … between 2 people [so] that pretty well no amount of talking even with the best communication skills quite equals what that means to people, so yeah, I think it is a huge part of it for both sides. If you didn't do that, then you're a technician, … we're not a physician anymore. We're healers, … and part of that is making a connection and an ultrasound machine is not a connection. (participant 14, female, urban practice, >20 years' experience)"

Performing physical examination was important because "going through the motions" reassured patients and fulfilled participants' role as physicians. A rural physician describes how you can learn physical examination only by doing it, eventually reaching a point where the physician's body knows exactly what to do. "You can talk about it, you can talk about the theory behind it, … but you have to do it" (participant 8, male, rural practice, >20 years' experience). Participants honed their styles over time. They took a "top to toe" approach, explaining what they were doing as they were going or making "small talk." They examined patients "almost without thinking." "Half the time they're so healthy, you might be … not totally focusing and maybe going through the motions because it's automatic at this stage" (participant 13, female, rural practice, 6–19 years' experience). Laying on hands somehow relayed information that participants had not registered intellectually. "The routine performance that reveals something more, there is a process about laying on of hands" participant 12, male, retired, urban practice, >20 years' experience).

Physical examination also had a temporal dimension. From something that "only takes a moment" when normal, the experience of time and "being in the moment" came to the fore when physical examination revealed the unexpected, such as a mass. Here, a family doctor describes being unable to hear the heartbeat of a fetus.

"How you manage that couple of minutes where you go searching. Is it my technique? Am I just missing it? Is the machine not going well, or do we really have a problem here? Trying to manage that 20 to probably 60 seconds of just awful anxiety without really deciding how much you're relaying to the patient during that timeframe… . There's just numerous things there … we're generally … unaware of … that suddenly become of absolute ultimate importance. (participant 14, female, urban practice, >20 years' experience)"

Physical examination was associated with physical reactions, experienced through the physician's body, as exemplified by the quotes above and below.

"You walk into a room, and you look at a kid and you go oops, and your stomach knots—that child is sick. All you have done is look at them, but you know that baby is not well. You get that urgent feeling in your body, telling yourself to breathe, tell me your story, breathe, give me that baby. I want to look at that baby. (participant 9, female, urban practice, >20 years' experience)"

Experiences of discovering something abnormal "just never leave you," "they are stuck in [your] mind" (participant 12, male). Repeated practice enabled participants to "know normal" in a physically embodied way. "It's that Gestalt feeling of this just doesn't feel the same, right, you know, the abdomen that feels a bit doughy or um, you know, it just feels different" (participant 1, female, urban practice, >20 years' experience).

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