Point: Routine Daily Physical Exams in Hospitalized Patients Are a Waste of Time

Abstract

Every day, physicians engage in an elaborate performance with their patients-the routine complete physical exam. We argue that this purportedly time-tested ritual is at best a waste of time, and at worst potentially harmful.The modern physical exam evolved throughout the 19th century as the first diagnostic tool in a medical field that was rapidly transforming from its traditional roots to a modern scientific discipline. 1 Despite the vast increase in diagnostic tools since then, the physical exam remains one of the most predictive. Several decades of investigation into the "evidence-based" physical exam have attempted to calculate the test characteristics of individual exam findings, confirming that the exam remains as useful a diagnostic tool today as it was for Laënnec or Osler. 2 Performing a physical exam for the purposes of diagnosis and prognosis-not only on admission, but also on a daily basis to assess treatment response-remains a fundamental part of a hospitalist's job. For example, a daily volume assessment, including cardiac auscultation for an S 3 , evaluation of the jugular venous pulse, and measurement of edema, is essential in managing patients with decompensated heart failure. However, when we stray from these diagnostic purposes, we are no longer using the exam as intended.The physical exam most frequently performed in the hospital today is the so-called routine daily exam. Generally, this involves passing a stethoscope fleetingly across the chest and abdomen, perhaps with some additional palpation of the abdomen. Cranial nerves II through XII may also occasionally be checked. This routine exam-and by extension, the templated physical exams that fill hospitalists' documentation-not only lack an evidence base, but also are arguably harmful to patients. Such exams should not be part of a hospitalist's daily practice.The most concerning aspect of a routine daily exam is that examination of an asymptomatic patient-for example, auscultation of the lungs of a patient admitted with lower extremity cellulitis-is fundamentally a screening rather than a diagnostic test. While little work has been done in the inpatient setting, decades of studies on outpatient screening exams demonstrate that very few of them are effective. 3 For example,

Counterpoint: Routine Daily Physical Exams Add Value for the Hospitalist and Patient

“…W e read with interest the perspective of Drs Rodman and Warnock, 1 but disagree with the authors on several points. We find that the routine daily physical examination, often neglected or unappreciated amidst technological advances and new diagnostic testing, provides significant value to both hospitalist and patient in terms of diagnosis, treatment, patient-centered care, and maintaining the patient-doctor relationship.…”