The physical exam is among the few commonalities in veterinary medicine.
When Ludwig, a 6-year-old Boxer, came in for his annual vaccinations and physical examination, he was showing signs of abdominal discomfort and had difficulty walking on his hindlimbs. My physical exam findings were normal except for apparent pain on abdominal palpation and unilateral cryptorchidism. Thus, I suspected that Ludwig had a retained testicle and that it could be causing a problem. I reviewed Ludwig's medical chart and could find no mention of a retained testicle. In fact, the medical record identified Ludwig as neutered.
David Robbins, DVM
I discussed my findings with the owner, who proceeded to tell me that in all the years of coming to the practice for exams, no one had ever mentioned the retained testicle. Furthermore, the owner said that no one had ever examined Ludwig's private region. She said, "They always seemed in a hurry to just vaccinate."
Duke's elusive diagnosis: An illustration of the importance of history taking
It turned out that Ludwig's retained testicle was cancerous. Unfortunately, by the time I saw Ludwig, the cancer had already spread throughout his abdominal cavity. However, it makes you wonder if a complete physical exam could have prevented this had one been done sooner.
The physical exam is the routine assessment of a patient by using our five senses and minimally invasive techniques, using for example a stethoscope, not a colonoscope.1 Together with the patient's history, the physical exam helps us determine whether additional diagnostic tests are indicated, and, if so, which tests will be most useful. The physical exam is among the few commonalities in veterinary medicine, practiced by every veterinarian trained in every country. Anyone who has practiced or observed veterinary medicine in an economically challenged setting knows the physical exam is often the only method available for diagnosing a patient's illness.
However, as technology continues to evolve in veterinary medicine, I am concerned about the future role of the physical exam in our profession. From advanced imaging in veterinary referral centers to sophisticated tests now available routinely in outpatient settings, technology has altered the way we diagnose, treat, and palliate disease. Are we putting too much emphasis on technology instead of on the physical exam? And, if so, is it changing the way we view the physical exam?
In my opinion, we are beginning to see the role of the physical exam de-emphasized. I have noticed more practitioners spending less time obtaining or reviewing a history and performing cursory physical exams in sick and healthy patients almost out of a need to be loyal to the process rather than valuing the information gathered. In modern veterinary medicine, diagnostic tests have supplanted clinical skills. Rather than relying on detecting a murmur during auscultation, we use an echocardiogram to tell us whether a patient has mitral insufficiency. And magnetic resonance imaging (MRI)—not a neurologic exam—tells us whether our patient has a brain lesion.
It may be easy to say that the physical exam is losing some of its potency because we are busier than ever and have less time to perform thorough physical exams. Although definitely a factor, our lack of time only partly explains this change. A decreased emphasis on physical exam skills in veterinary schools, the fear of uncertainty, the availability of sophisticated diagnostic tests, and even financial factors also play roles in the demise of the physical exam.
In talking with new graduates over the years, I've concluded that many veterinary schools are not emphasizing the physical exam. I remember taking a physical diagnosis class as a sophomore in veterinary school. A general practitioner taught the course, and she had mixed feelings regarding the value of the skills she was teaching. The course was a pass-or-no-pass, one-unit class sandwiched between rigorous physiology and anatomy courses. It was a fun but devalued class, and we students viewed it as a rest stop, a break from the rigors of the important subjects.
In that class, we did learn about the importance of a wellness exam, but we spent little time on abnormal findings because those were to be covered in clinics. Unfortunately, I encountered similar attitudes toward physical diagnosis in clinics. Many of the interns and residents focused on teaching the value of running diagnostic tests instead of conducting good physical exams. Who had time to perform a complete physical exam? We all had to check on 12 patients and participate in rounds.
As today's clinical faculty faces increasing time constraints, it's likely that even less time is being spent on teaching physical diagnostic skills. Another reason educators may not be emphasizing these skills is because they lack confidence in their skills. Some teachers' greatest vulnerabilities may be in the clinics.
If a physical exam permits a veterinarian to diagnose a herniated intervertebral disk with only 99% probability, then there is an almost irresistible urge to perform an MRI to close the gap. This is the fear of uncertainty. Further compounding this fear is pressure from the legal profession.
Although a poor reason to order diagnostic tests, the litigious nature of our society often demands it. Since so much more is now known and knowable in veterinary medicine than in the past, our profession is viewed as an absolute science. As a result, more of us are shying away from making educated guesses based on the physical exam findings and are practicing defensive medicine for fear of being sued.
Some believe that it is good science to use our new technology earlier and more prevalently—the technology as a toy argument.2 By playing with the toy, we can learn to use it better and, perhaps, discover the unexpected. Moreover, there are greater financial rewards for ordering tests than for picking up on subtle physical exam findings.
Technology can produce good science—the discoveries by Galileo through his telescope, for example.2 But technology can mislead, such as when an incidental finding on a radiograph or an artifactually elevated laboratory value on a screening blood test is misinterpreted. And even finely tuned electronic instruments may not offer definitive results.
Nevertheless, we highly value technology. Yet the physical exam has certain advantages over sophisticated tests and tools. For example, it is less expensive, and, unlike many high-tech diagnostic tools, it can be performed anywhere. In addition, the physical exam can be used more easily to make serial observations. And because it involves touch, the exam enhances the veterinarian-patient-client relationship.
In addition, even in today's technologic times, some practitioners still embrace the physical exam as something almost mystical. They see the true value in auscultating the chest or in palpating the abdomen before taking further diagnostic tests. These veterinarians remind themselves that some of the greatest achievements throughout medicine have been based on observation, thorough history taking, and a physical exam. For example, long before the invention of the electrocardiogram, Karel Wenckebach, an early 20th-century physician, discovered the heart block arrhythmia by timing a patient's arterial and venous pulsation.
Without a doubt, the veterinary medicine of today is not the veterinary medicine of the last decade. However, despite the many advances in technology, the history and physical exam will remain constants in veterinary medicine. Dermatologists will continue to depend on observation and palpation to recognize skin problems. And neurologists, while greatly helped by computed tomography and MRI, will continue to rely on a patient's history and physical exam results to correlate pathology with functional changes. Practitioners, too, must not lose touch with this central component of patient evaluation.
As Sir William Osler said, "Learn to see, learn to hear, learn to feel, learn to smell and know that by practice alone can you become experts."3 It is the fusion of the physical exam, the patient's history, and technology that will help veterinarians become more accurate, quicker diagnosticians and healers while maintaining the crucial veterinarian-patient-client bond.
David Robbins, DVM
VCA West Bernardo Animal Hospital
11605 Duenda Road, Suite D
San Diego, CA 92127
1. Phoon CK. Must doctors still examine patients? Perspect Biol Med 2000;43(4):548-561.
2. Flegel KM. Does the physical examination have a future? CMAJ. 1999;161(9):1117-1118.
3. Bean WB. Sir William Osler: aphorisms from his bedside teachings and writings. Springfield, Ill: Charles C. Thomas Publisher, 1961;129.