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

Discussion

Participants experienced physical examination as an integral part of being a good doctor. It helped them rule physical diagnoses in or out and yielded unexpected findings. Diagnosis and prognosis were only 2 functions of physical examination, however. It also had subjective functions that were inextricably linked to its objective functions. Physical examination enacted physicians' identities in fluent but individual ways. It built empathic relationships between them and patients. Depending on its content and context, physical examination made time stand still or rush by. The embodied experience of physical examination was a means of knowing the normal and being surprised by the abnormal, a means of experiencing and remembering.

Our study has limitations. We do not know what patients experienced or what they expected. However, previous studies indicate that patients expect to be examined and are less satisfied when physicians do not examine them.[38,39] We did not directly observe participants' physical examinations and relied on their self-reports, sometimes long after the events they described. A key feature of this type of work, its interpretive nature, limits its generalizability. Our sample is small, and other physicians may not necessarily share these experiences in a similar manner. Our participants self-selected into this research, and it is possible that they did so based on the perceived value of physical examination. We did not ask participants their views on the relative merits or drawbacks of physical examination but only about their direct experiences performing it. Other researchers might have conducted the interviews differently and interpreted the data in different ways. A different method, such as observational research, or a questionnaire study could reveal different insights.

Having noted those limitations, we emphasize that our purpose was not to present "facts" but to gain meaningful insights, recognizing that all interpretations are tentative. Interpretive research of this type is made more rigorous by the use of preexisting theory as an interpretive tool. Our interpretation of physical examination as an embodied human interaction resonates with the work of French philosopher Maurice Merleau-Ponty, who proposed that it is impossible to separate mind and body. Physicians' experiences mirror his argument that the body is not an object but an agent in meaning making.[29] Repeated performances of tasks become habits of practice. Physicians' bodies accumulate experience and become finely tuned, responsive to the moment. They can perform physical examination almost without thought because their bodies understand in a prelogical, prereflective manner. More than a routine or a cognitive process, physical examination is a creative engagement between the body of a physician and the body of a patient. The act of physical examination brings our human connection to the fore, it brings forth vulnerability, but in doing so it reveals our interrelatedness in the world.

The implications of this work are to highlight relational aspects of physical examination and encourage fellow practitioners to engage in a dialog that treats physical examination holistically rather than as only a diagnostic tool. The evidence this research contributes to that dialog is that experienced family physicians performed physical examination "even when it wasn't needed (diagnostically)" to build rapport, continuity, and trust. Physical examination facilitated nonverbal communication, mediated by touch,[37] facial expression, and use of space. Participants emphasized that laying on hands demonstrated they were attentive to patients' concerns. It signaled "being there."

This work also has implications for research. A recent review of touch[40]—the sense that mediates contact between physicians' and patients' bodies in the course of physical examination—found numerous articles from other professions, chiefly nursing, but only 4 qualitative studies in medicine, 2 set in UK family medicine.[41,42] Touch was an important part of nonverbal communication, but it was fraught with tensions between expressing caring and risking professional sanction. Physical examination was a therapeutic intervention in itself,[43] not solely a means of making diagnoses. To date, the physician's body has been largely absent[44–46] from health care literature. Rather than a neutral conveyer and interpreter of physical facts, we propose the physician's body is an active agent. Further research could attend to both nonverbal communication and subtle sensory responses, which would offer new ways of understanding doctor-patient engagement. It could also address an important limitation of this study by examining the intersubjective experience of physical examination from both patients' and physicians' perspectives, perhaps based on direct observation and less subject to recall bias.

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