The diagnostic process 2021: patient brings in printout of weird shit, insists that’s what’s wrong with him/her, big fight with GP, ultimate diagnosis: physical and psychical trauma all round, right? It’s an insult to general practice, given that it ignores the holy diagnostic trinity of history, examination and investigations – which, I think we’d agree, is still sacrosanct. Except, somewhere along the line, the ‘examination’ has been unceremoniously dumped.
True, I’ve never been a great fan of the physical examination. I’ve always argued that the history does the diagnostic heavy lifting, and the heavy lifting required to peel my arse from consulting chair to examination couch is too much effort, particularly given that the hands-on stuff is largely ritualistic placatory bollocks.
Plus, the personal hygiene of some patients – forcing me to use triple PPE and approach them as I would a radioactive isotope – is a powerful disincentive to getting up close and personal. But I do fear the pendulum is swinging too far the other way. These days, just about every aspect of modern medicine shoves the good old physical examination closer to the clinical obsolescence bin.
For starters, we’re still doing much of our consulting by remote – which immediately raises the threshold for any hands-on work.
Simultaneously, the profession seems to be having a crisis of physical examination confidence – perhaps through falling out of the habit, or deskilling, or a genuine belief that we may as well Go Directly To Scan: after all, ordering one is just a mouse click away.
And that’s what the punters want, isn’t it? We’ve all received complaints for failing to investigate, of course. But, ‘I wish to complain about Dr Copperfield for sending me for an unnecessary MRI’? Said no one. Ever.
But hang on. Skipping the examination really does drive a coach and horses through traditional medicine. There are good reasons why it has survived until now and we should think twice before completely trashing it.
Doing so will inevitably lead to overinvestigation, and you don’t need to be the duty doctor weeping over lab reports at 8.45pm to know this leads to over-medicalisation of patients and demoralisation of GPs.
Besides, we are missing a trick here. Specifically, the one we play on patients through the laying on of hands. We all know this is largely placebo but so what? If the pandemic has taught us one thing, it’s how we’ve underestimated the power of in-person consulting in general, and the value of touch in particular.
Now, you might well argue that the phrase, ‘the value of touch’ has no place in a Copperfield column unless it’s about punching a heartsink in the face. Yet it’s true: the physical exam has benefits in terms of therapy and trust way beyond the effort expended. The proof? All those musculoskeletal patients currently bending your ear because their appointment for physio – the most hands-on of all specialties – has degenerated into texted exercise sheets.
So I vote to save the physical exam. As long as they take a shower first.
Dr Tony Copperfield is a GP in Essex. Read more of Copperfield’s blogs at http://www.pulsetoday.co.uk/views/copperfield