Beyond the obvious: the intangible value of the physical exam

The physical examination has long stood as a cornerstone of clinical medicine, embodying the tangible connection between patient and clinician. The art of medicine is deeply rooted in the seasoned clinician’s discerning gaze and skilled hands. As we talk about the future of healthcare, the physical exam often finds itself in the crosshairs, questioned for its relevance in an era where a significant portion of healthcare delivery is becoming virtual or being considered for automation. Depending on source and specialty in question, the percentage of care delivery that could be made virtual ranges from 30% to 70%—analyses often focus only on its tangible utility in collecting meaningful clinical information. However, it may be the intangible aspects of the physical exam that hold a greater merit in the future of healthcare delivery.The tangiblesAt its core, the physical exam provides invaluable clinical data, frequently contributing to the making of nuanced clinical decisions, from the quick assessment of fluid status in a nephrologist’s office to crucial life-death decisions in the emergency department. These are extracted by the expert clinician through direct interaction with the patient. The value of this information is especially important in scenarios where there is a high degree of ambiguity or acuity, such as a young patient presenting with sudden abdominal pain. Virtualizing such a presentation efficiently (i.e. without doing an ultrasound in every case) in the present day context is a challenge and often leads to unnecessary emergency visits or escalated care, inadvertently driving up healthcare costs.There is a lot of complexity in trying to unravel the breadth of the tangible utility of the clinical exam. First, the immense variability of the real world can mean that a human clinician needs to be able to contextually draw relevance in the circumstance in front of them. The visit says it is about “rash on arm,” however the person in front of me looks confused, disoriented and in visible discomfort. Or perhaps a patient is coming in for a preventative health assessment to discuss genetic testing, but I notice a new bruise around their left eye and the fact that their gaze is down, avoiding eye contact. I might even just “feel” that something is different with a patient I know well, the result of which is me probing more broadly: “Are you doing okay? Is there something else you wanted to talk about?”As well, human clinical judgement doesn’t restrict itself to a particular time or space. A nurse may be walking down to get a coffee in a hospital cafeteria during their break, when they notice someone slouched over and gripping their chest.It is, of course, the utility of the clinical data itself that concerns most conversations on physical exams. Many clinical heuristics, as we know them today, are highly dependent on this data in order to be able to accurately make expert clinical decisions—while the practice of medicine has significant gaps in its ability to capture competency, error and quality of physical exam skills. There has also been a cultural shift over the last few decades towards more lab and imaging tests, reducing the relevance of the clinical exam; yet we don't have the technology to entirely dispense with it either.The intangiblesThere are a number of benefits to the physical exam that are often overlooked when the focus is solely on its utility for clinical data extraction.By consenting to be examined, the patient presents themselves as available and open to the receipt of healthcare. While consent may also be obtained verbally or in writing, the physical exam is symbolic and reflects the shared understanding of trust. Replacing this purely with a legal document or process may contribute to the feeling of sterility and indifference between both the patient and the care delivery system.The empathy demonstrated during a physical exam can have a profound therapeutic effect. Acknowledging a patient’s suffering and showing genuine concern can catalyze the healing process, highlighting the psychological and emotional dimensions of patient care. I discussed empathy and AI in my last blog, where I highlighted that it may very well be possible for AI to achieve human-level or superhuman skills in empathic communication. The human-to-human connection of physical touch and acknowledgement by another living being however, is a different matter, and undoubtedly more challenging to replicate.Then there is the matter of ritual. The physical exam as a ritual has been part of human tradition across cultures for thousands of years. Going back to Ancient Greece, Hippocrates was famous for highlighting the important of observation and examination in the process of healing. Stanford physician, author and professor, Dr. Abraham Verghese has been a long time advocate of the benefits of the physical exam, and in particular, it’s role in ritual. In his 2021 paper titled “The Bedside Evaluation: Ritual and Reason”, he writes:“The ritual is a key part of the commitment to medicine, and in carrying it out, personal creativity and skill can find play in a form that accomplishes essential gathering of information, while conveying a symbolic centering of attention on the body as a locus of personhood as well as disease.”Lastly, the physical exam is an indispensable tool for learning and skill enhancement. Hands-on experience has been central for the understanding of disease manifestations, treatment effectiveness and diagnostic techniques, ultimately benefiting patient care. In order to be able to have, at bare minimum, back-up diagnostic redundancy (let’s say if the power goes out and AI is “temporarily unavailable”), adequate competence in human clinicians needs to be considered.What kind of future do we want?Society evolves, as do humans, our cultural preferences and rituals that define our existence.We will march towards progress as we always do. Knowing that there is more to the art of medicine than meets the eye may mean that we build AI tooling to mimic empathy, to build new rituals, to deliver a human-like healing touch. I certainly think over time these and more will be possible.There is also an alternative that is deeply compelling. The physical exam may be one of the domains in the practice of medicine with an essence we choose to build a moat around. Yes, we augment the capability of the human clinician with technology—providing richer data, improving accuracy and quality of care. Yes, not every interaction in healthcare may warrant it, and we virtualize/automate appropriate scenarios. And yes, the ritual itself may evolve, looking much less like the physical exams of the last 100 years. But the human touch may not remain a part of care delivery if we do not preserve it, do not prioritize it, for those moments where it is needed the most. Perhaps there is merit to not only allowing the human to remain in the loop, but to actually restore and celebrate their capacity to provide a healing touch as we have sought for centuries. To trust another person to enter a life during a dark time, providing the reassurance of knowing that, in the big world, there is at least one other person who cares. As long as we live in this dimension and as long as we have human bodies that require care, perhaps there is merit.Dr. Puneet Seth is a Toronto-based family doctor and technologist whose work focuses on building tools for the future of healthcare. He is also the founder and host of North of Patient, a podcast and blog exploring the intersection of the future of healthcare, technology and the humanities. This article was originally posted in the North of Patient blog.

Beyond the obvious: the intangible value of the physical exam

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Puneet Seth

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