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The Value of the Physical Examination in Clinical Practice: an International Survey

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The Value of the Physical Examination in Clinical Practice: an International Survey ORIGINAL RESEARCH Clinical Medicine 2017 Vol 17, No 6: 490–8 T h e v a l u e o f t h e p h y s i c a l e x a m i n a t i o n i n c l i n i c a l p r a c t i c e : an international survey Authors: A n d r e w T E l d e r , A I C h r i s M c M a n u s ,B A l a n P a t r i c k , C K i c h u N a i r , D L o u e l l a V a u g h a n E a n d J a n e D a c r e F A structured online survey was used to establish the views of the act of physically examining a patient sits at the very heart 2,684 practising clinicians of all ages in multiple countries of the clinical encounter and is vital in establishing a healthy about the value of the physical examination in the contempo- therapeutic relationship with patients.7 Critics of the physical rary practice of internal medicine. 70% felt that physical exam- examination cite its variable reproducibility and the utility of ination was ‘almost always valuable’ in acute general medical more sensitive bedside tools, such as point of care ultrasound, ABSTRACT referrals. 66% of trainees felt that they were never observed by in place of traditional methods.2,8 a consultant when undertaking physical examination and 31% Amid this uncertainty, there is little published information that consultants never demonstrated their use of the physical describing clinicians’ opinions about the value of physical examination to them. Auscultation for pulmonary wheezes examination in contemporary clinical practice. Similarly, and crackles were the two signs most likely to be rated as although some understanding of the comparative value of frequently used and useful, with the character of the jugular different components of the physical examination can be venous waveform most likely to be rated as infrequently used inferred from diagnostic utility studies,3 clinicians’ opinions and not useful. Physicians in contemporary hospital general about the relative value of different physical examination signs medical practice continue to value the contribution of the or manouevres (PESM) have never been formally explored. We physical examination to assessment of outpatients and inpa- therefore surveyed secondary care clinicians practising general tients, but, in the opinion of trainees, teaching and demonstra- internal medicine about the value of physical examination in tion could be improved. their own day-to-day practice. K E Y W O R D S : Bedside medicine , medical education , physical exami- M e t h o d s nation , physical signs Eligibility to participate Clinicians of any level of experience that were involved in Introduction the care of adult patients referred to acute hospital admitting Over the past 30 years, increasing use of technology has cast services or general medical outpatient clinics at the time of the doubt on the value of physical examination in contemporary survey or within the previous 2 years were eligible to participate. patient care. 1,2 The perception that physical examination has limited value Q u e s t i o n n a i r e has developed despite the substantial literature demonstrating that many of its components possess diagnostic utility,3,4 t h a t The questionnaire was designed by two authors, then modified it still contributes to diagnosis, 5 and that poorly performed following feedback from a small-scale pilot in 20 clinicians, or completely omitted physical examination contributes to with minor changes to language and ordering of questions. clinical errors. 6 It is also argued, perhaps most importantly, that S u r v e y c o n t e n t The final survey can be found in supplementary file S1. The first part (Questions 1–9) established basic demographic Authors: A medical director, MRCP(UK), London, UK ; B professor of information, the second (Questions 10–17) asked general psychology and medical education, University College London, questions regarding physical examination and its teaching, London, UK ; C consultant and physician and honorary senior and the third (Questions 18–21) contained specific questions lecturer, Royal Infirmary of Edinburgh, Edinburgh, UK ; D professor about a series of 58 specific PESMs selected to cover the broad of medicine and deputy dean (clinical affairs), School of Medicine variety that may be used in general internal medical practice and Public Health, Newcastle, Australia ; E consultant physician and and most commonly represented in textbooks of physical senior clinical research fellow, North-west London CLAHRC, London, examination. Of these, 19 PESMs related to the nervous system, U K ; F professor of medical education and president, Royal College of 11 to the cardiovascular system, nine to the abdomen and Physicians, London, UK gastrointestinal tract, nine to the respiratory system, three each 490 © Royal College of Physicians 2017. All rights reserved. CMJv17n6-Elder.indd 490 11/13/17 4:29 PM The value of the physical examination to locomotor and endocrine systems and four to other aspects Table 1. Demographics of 2,684 respondents who of physical examination. Participants were asked to consider each question in the met the criteria for inclusion in the study context of their general internal medicine work rather than Characteristic n (%) any specialty work and to classify each PESM in relation to the Sex (NA * =25) frequency of their own use (relatively infrequent or relatively Female 921 (34.6) frequent) and the value they attributed to the PESM when used Male 1,738 (65.4) (useful or not useful). Current clinical position An open text box could be used for any additional comments. Consultant or other career grade 1,222 (45.5) E t h i c a l a p p r o v a l Training grade 1,387 (51.7) Retired 25 (0.9) Ethical approval was received from University College London Not currently working 50 (1.9) and the Royal College of Physicians of Ireland. Country of primary medical qualification UK 982 (36.6) Dissemination of the study questionnaire European Economic Area (excluding UK) 261 (9.7) The study was primarily promoted by a single email invitation Rest of the world 1,441 (53.7) to affiliates of royal colleges of physicians in the UK, Ireland, Has MRCP(UK) or similar Australia and New Zealand, the Society for Acute Medicine No 1,239 (46.2) and to trainees around the world who had sat the MRCP(UK) Yes 1,445 (53.8) examination (11,347 direct invitations). The survey was also advertised in general form within e-bulletins circulated by the Is an MRCP(UK) or similar examiner (NA=16) UK colleges of physicians. The survey was open from 1 January No 2,135 (80.0) 2014 until 31 March 2014 and hosted online by a commercial Yes 533 (20.0) company (SurveyMonkey). Country of general medical experience (NA=17) UK 1,225 (45.9) Statistical methods and analysis European Economic Area (EEA, excluding UK and 234 (8.8) a) Respondents included in the analysis Ireland) A total of 3,706 physicians (32.7% overall response rate) Other non-EEA/UK 1,208 (45.3) returned the online questionnaire. However, 130 respondents > Ireland 207 (7.7) did not fulfil the primary eligibility question and were excluded > Australia 199 (7.4) from the analysis. Questions 18 to 21 asked about each of the 58 > Sudan 141 (5.3) PESM and analysis was restricted to the 2,684 physicians who > Pakistan 130 (4.8) answered at least 50 of these questions. > India 120 (4.5) b) PESM utility scale > USA 13 (0.5) A simple scoring system based on possible combinations of > Other 398 (14) responses to questions about each PESM was devised to provide Year of primary medical qualification (NA=4) a metric of each respondent’s overall perception of the value Pre-1980 236 (8.8) of physical examination and compare the relative value of 1980–1989 331(12.4) different PESM across multiple respondents. In this system, 1990–1999 491 (18.3) the combination of ‘relatively infrequent: not useful’ scored 1; 2000–2012 1,622 (60.5) ‘relatively frequent: not useful’ scored 2; ‘relatively infrequent: useful’ scored 3 and ‘relatively frequent: useful’ scored 4. Median year of primary medical qualification 2002 Interquartile range of year of primary medical 1992–2007 c) Statistical analysis qualification Statistical analyses were carried out with IBM SPSS 22.0. Specialty (n=2,681) Inferential statistics included Pearson correlations, t-tests, General medicine 482 (18) one-way ANOVA and multiple regression. In view of the large Geriatric medicine 396 (14.8) sample size and the exploratory nature of some of the analyses, Acute medicine 240 (9) the alpha level was set at p = 0.001 to reduce the likelihood Diabetes and/or endocrinology 221 (8) of type 1 errors. The PESM scores for physicians in different specialties were compared using oneway ANOVA, with an alpha Cardiology 191 (7) of p<0.001. Post hoc comparisons used the Ryan-Einot-Gabriel- Gastroenterology and hepatology 179 (7) Welsch (REGW) range, also with an alpha of p<0.001. Respiratory medicine 165 (6) Nephrology 128 (5) R e s u l t s Neurology 67 (2.5) Table 1 summarises the demographics of the 2,684 respondents Others/multiple/not specified 599 (22.3) included in the analysis. Location of clinical experience was *Some respondents did not answer (NA) all questions © Royal College of Physicians 2017.
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