What to expect in a general physical examination

Tieng Viet

Introduction

If you have had more than one primary care doctor you will probably notice no two doctors follow the same procedure for a general physical check-up. Moreover, the textbook physical examination shown on this website is seldom executed to the fullest extent. Some patients might prefer putting blind faith in their healthcare provider but considering our profit-driven society it would be wiser to be more inquisitive and vigilant. The fundamental question is whether the examination adequately ensures our protection by detecting early signs of diseases while we are apparently healthy. A less than thorough examination could be detrimental to our health and speaks volumes about the quality of care we are receiving.

Variability in implementation

Let’s review first the alternative types of physical examinations we could encounter in a clinical setting besides the textbook approach. Most healthcare providers tend to consider the thorough and comprehensive textbook type covering all the relevant body systems and signs, as more applicable to novice clinicians, students, or researchers who need a systematic and consistent approach. Leveraging professional experience and prerogative they could sidestep the comprehensive approach by finding it too time-consuming, unnecessary, or impractical in some situations, such as when the patient has a specific complaint, when the clinician has limited resources, or when the evidence does not support the textbook recommendations. The providers could then opt for either of two general alternatives: the evidence-based or practical type.

Evidence-based type: This is the type of physical examination that is based on the best available scientific evidence and clinical judgment. It aims to use the most accurate and reliable tests and findings to diagnose and manage the patient’s condition. It may be useful for improving the quality and efficiency of care, reducing errors and harm, and informing decision-making. However, it may also be challenging, controversial, or incomplete in some situations, such as when the evidence is scarce, conflicting, or outdated, when the clinician has to balance multiple factors, or when the patient has preferences or values that differ from the evidence (1).

Practical type: This is the type of physical examination that is based on the clinician’s experience and intuition. It relies on the clinician’s skills and knowledge to perform the most relevant and feasible tests and findings for the patient’s situation. It may be useful for adapting to the real-world constraints and complexities of clinical practice, such as when the patient has multiple or chronic problems, when the clinician has to work with limited time or resources, or when the patient has a strong rapport or trust with the clinician. However, it may also be subjective, variable, or biased in some situations, such as when the clinician has gaps or errors in their knowledge, when the clinician has personal or professional conflicts of interest, or when the patient has expectations or demands that differ from the clinician’s judgment (2).

References

(1)    The Rational Clinical Examination

(2)    Evidence-Based Physical Examination Textbook and Handbook Set

 

Factors affecting the choices of alternative physical examinations

Training and Background: Doctors come from diverse medical schools and training programs. They might have been taught slightly different approaches or emphasize certain aspects based on their experiences.

Clinical Judgment: Physicians may prioritize certain examinations based on their clinical judgment. They might focus more on specific systems or areas based on the patient's medical history, complaints, or risk factors.

Preferences and Specializations: Some doctors might have particular interests or specialties that influence their examination techniques. For instance, a physician with a background in sports medicine might emphasize musculoskeletal exams more than others.

Patient Variability: Each patient is unique, and their physical condition may necessitate variations in examination techniques. Factors like age, gender, ethnicity, and lifestyle choices might influence the examination approach.

Would a strict physical examination protocol be more beneficial to both patients and healthcare providers?

Implementation of a strict protocol could ease the mind of patients and healthcare providers but unfortunately there is no consensus on the subject. While a strict protocol might seem beneficial, medicine is as much an art as it is a science. Flexibility allows doctors to adapt their approach to suit individual patient needs. However, there are standardized guidelines and protocols for specific aspects of physical examinations, like those established by organizations such as the American College of Physicians or the U.S. Preventive Services Task Force. These guidelines provide a framework for doctors to follow while allowing room for clinical judgment.

The variability in examination techniques doesn't necessarily imply inconsistency in quality. What's important is that the doctor covers the essential aspects of a physical exam, ensures patient comfort, and addresses any specific concerns or findings. Communication between doctors and patients about the procedures being performed and the reasons behind them can also help build trust and understanding.

Evaluating your healthcare provider during physical examinations

The physical examination we are addressing here is that of a healthy person with no specific complaint of any ailments. There is a standard set of criteria most patients use to evaluate their doctors, namely credentials & experience, reviews & referrals, professionalism, and more importantly outcomes & follow-ups. Most often overlooked is the need to be informed, to ask questions and observe the communication skills of the doctor. The latter is most important during the physical examination. A good start for being informed consists of consulting the relevant webpages on personal and family medical history through all components of physical examinations. The checklist will serve as the basis for effective communication with the healthcare provider. It would be fair to inquire tactfully if any steps are ignored. All patients deserve thoughtful explanations from their healthcare providers. The quality of the answers provides a window into bedside manners, professional competence and level of attention to detail. The primary care doctor is our first line of defense. Selecting the most competent one is most essential for our health maintenance, and we should not hesitate to seek a second opinion if anything feels ajar.

Examples of details to watch for during a physical examination