6 Physical examination and clinical investigation
Other ways of knowing
Although physical examination is presented here as a distinct and separate section of this book, it is not necessarily enacted as a separate part of the consultation. We mentioned at the end of the last chapter that examination may occur at various points during the case history-taking, either because the practitioner asks permission to examine phenomena as they arise, or because the patient proffers part of the body to viewed, e.g. rolling up a trouser leg when describing their swollen ankles. Yet physical examination can be considered as extending beyond this into every moment of the encounter with the patient, beginning with the very first contact. This insight is gained when we consider an extended definition of physical examination as one having to do with the practitioner’s use of her senses to comprehend the physical dimensions of the patient’s being and expression. This is a process that is constantly in a state of play, although much of the value will be missed if the practitioner fails to attend to this fact. Examples of ‘physical examination’, seen from this orientation, include:
• Hearing: hoarseness in the patient’s voice; a cough; laboured or altered breath sounds; or sniffing. All these phenomena could be detected in a preliminary telephone consultation before seeing the patient for the first time
• Seeing: the patient’s difficulty in rising from a chair; observing their posture and gait; tremor; skin tone and colouration. Such significant areas of examination can be noted from the time of first greeting a patient in the waiting room, to the moment they sit down in the consulting room
In this view, ‘physical examination’ can be divided into two fields of activity: first, a general and continuous sense-awareness of the patient’s physicality; and second, specific time-limited techniques of formal, explicit physical assessment. In each instance, the core work involves the practitioner’s sensory engagement with the patient. To be regarded in this manner; that is, to be seen, heard, touched and smelled, can be a powerfully positive experience wherein the patient feels that they have been closely and carefully appreciated by the practitioner. It can also be an indifferent or unpleasant experience. Whether, and to what degree, the patient finds physical examination to possess positive or negative qualities will depend on a number of factors, including:
• The practitioner’s approach to handling bodies – in general and in particular. There is a difference for example, between sensory and sensual engagement; and between an appropriately ‘clinical’ manner and objectification of the patient’s body
Physical examination yields both gross and subtle signs and these can be interpreted differently depending on the reference point/s of the practitioner. Phytotherapy courses tend to emphasize the biomedical approach to physical examination as a diagnostic means, yet phytotherapists are also usually interested in traditional approaches to this area and may integrate alternative perspectives (some of which are considered below), with the conventional model. In doing this, it is important that herbal practitioners are able to provide a coherent explanation of their approach and findings to patients.
These represent entirely diagnostic goals, which do not fully account for the urge to examine. The predicaments and conditions of many patients (such as those classed as mood disorders) are not readily suggestive of the need for formal physical examination of any particular type, while many of the presentations that do indicate the involvement of a body system that is susceptible to examination fail to yield classical findings. In the latter case, either nothing of obvious consequence is found or the significance of the findings are unclear or deemed of poor legitimacy, e.g. generalized mild abdominal tenderness in the absence of other signs is conventionally read as indicating that, whatever the problem is, it probably isn’t serious. While classical findings may be encountered relatively frequently in acute or severe pathology, they are rather rare in day-to-day practice outside of hospitals. Routine physical examination is typically similarly unproductive in generating clear evidence of pathology. The value of physical examination is brought into further question by the superior ability of many laboratory and technological techniques to see into the body and by the rise of evidence-based physical examination, which has highlighted the deficiencies of many examination techniques, as we will see shortly. Despite all this, however, physical examination continues to be taught as an essential facet of the consultation. In my view, Greaves (1996) critique of, and rationale for, the use of physical examination in conventional medicine could apply equally to herbal practitioners:
The physical examination, when it is carried out, is often restricted to just one or two simple procedures, such as taking the pulse, measuring the blood pressure or listening to the chest. Although these procedures may sometimes be of value for clinical purposes, their rather frequent and non-selective use cannot be explained solely in these terms. They would seem to have an additional significance: that of a symbolic routine, which may provide benefit to the patient and marks out the special content of the doctor’s work over and above that of technical expertise. It allows the possibility of apparently straightforward clinical tasks embodying a personal quality which only gains meaning from the responsiveness of the patient in return, and so is shared by the doctor and the patient.
Although significant (meaning ‘disease indicating’), diagnostic clinical findings are sometimes discovered, the ‘benefit to the patient’ more frequently lies in other areas – especially in the very absence of ‘significant’ results. Physical examination represents a potent means of providing patients with reassurance regarding the nature of their condition. When the practitioner skilfully applies her senses to scrutinize the bodily area of concern and, following careful reflection, declares that all seems to be well, this may provide huge relief to the patient and restore confidence in the integrity of her own body to the extent that a ‘significant’ therapeutic influence has been exerted. The combination of laying-on of hands and reassurance can constitute an act of healing that the wise practitioner will be slow to spurn. This potential is lost when the examination is casual or perfunctory but is maximized when the ritual is performed solemnly, carefully and thoughtfully.
Once the healing potential of physical examination is recognized, the ways in which it can be applied need to undergo a review. The practitioner may decide, for example, to use physical examination with greater frequency and more serious attention. There may also be a new tendency to bring it to bear in circumstances where it would formerly have been dismissed as unlikely to be worth the effort or superfluous to requirements since the diagnosis has already been made on the history alone. Tension headache is an example where positive clinical findings (meaning definite physical signs of pathology) are rarely discovered on examination but it is a good example of a condition where careful physical examination can provide strong reassurance (patients with pronounced headache may secretly fear that they have brain tumours for instance), and might result in a lessening of symptoms. In such cases, physical examination presents a therapeutic opportunity more than a diagnostic one. To miss such an opportunity may actually lessen patient trust and adversely affect the therapeutic alliance. It is common to hear patients complain about seeing another practitioner, saying something along the lines of: ‘I told her I had this pain and she didn’t even touch me’. I remember explaining to one patient that this was probably because the practitioner thought it unlikely that she would find anything of clinical significance but the patient was unpersuaded: ‘Yes, but she should still have tried’.
Greaves’ highlighting of the personal nature of physical examination and the unique meaning dynamic of the patient–practitioner relationship in this part of the clinical encounter is important. Physical examination provides an opportunity for the practitioner to tangibly demonstrate care for the patient and to shift the consultation from an essentially cerebral dimension to a physical one. In making this shift, the patient is considered in a different way to that operating during the history taking and this may give rise to a sense of being considered more completely. While the history appears (deceptively) passive, the physical examination demonstrates clear action and may additionally provide a degree of release of psychological tension generated during the history-taking.
Physical examination therefore has to do with much more than diagnosis. Two of its key powers lie within its capacity to reassure and provide tangible personal care. It is a sensory means of knowing and relating that may dissipate tension and serve to ‘earth’ or ground the consultation. It may be therapeutically indicated even where it is not clinically so.
‘Physical examination’ is also known as ‘physical diagnosis’ and ‘clinical examination’. It can be contrasted with ‘clinical investigation’, which refers to laboratory and other types of testing such as blood studies and imaging techniques. A group of differences between ‘examination’ and ‘investigation’ are implied here and are summarized in Table 6.1. The two key distinguishing features between these two notions have to do with the proximity of the practitioner to the patient, and with the means applied to make the assessment.
|Performed by the practitioner||Performed by another|
|Embedded in the consultation||Occurring outside of the consultation|
|‘Soft’ evidence||‘Hard’ evidence|
|Considered subjective||Considered objective|
|Immediate results||Mostly delayed results|
|Generally non-invasive||More likely to be invasive|
|Very low to no risk of adverse effects||Adverse effects more likely|
In examination the practitioner is present with the patient and assesses her at close quarters using her senses, with little equipment involved (and where it is used, it is rudimentary, e.g. the stethoscope) – the practitioner is the active generator of findings. Investigation normally takes place in the absence of the practitioner (i.e. is performed by another person), and relies upon technical equipment – the practitioner is the passive recipient of results. While examination arises and takes place within the consultation and makes information available immediately, investigation takes place removed from the consultation and there may be a time lag of weeks between a test being ordered and the results being delivered. Patients’ thoughts and feelings about these two modes of exploration can vary, for example patients may consider investigations to offer more definitive results than examination but can be more anxious about undergoing investigations, especially where these are invasive.
Physical examination is an attempt to conjecture from manifestations appearing on the surface of the body about what may be taking place inside of it. Ancient systems of medicine developed sophisticated schemas of interpretation around key examination areas such as those of the pulse and tongue to the extent that these were relied upon to provide definitive accounts of the patient’s condition. (Previously, we quoted Kuriyama 1999: ‘In the second century B.C.E., in the earliest case histories of China, the sick summon Chunyu Yi not with vague pleas for succor, but with the specific wish that he come and feel their pulse’.) The pulse remains a ‘vital sign’ in biomedicine but it is not felt anymore – rather it is counted or transmogrified into a line on an ECG trace, the varied and multiplied forms of which suggest the outlines of mountains in early Chinese landscape art.
In Chinese medicine, the pulse is categorized with words such as: floating, deep, empty, slippery, choppy, soggy, hollow, scattered, wiry, overflowing, knotted, hasty; words which relate to natural phenomena and qualities drawing on such reference points as the properties and activities of water. Pulses are further described and taught in terms that relate to the natural world, for example, regarding the ‘slippery’ pulse: ‘In ancient times, it was described as feeling like ‘pearls rolling in a basin’ or ‘raindrops rolling on a lotus leaf’’ (Maciocia 2004). In contemporary biomedicine the lexicon relating to the pulse retains some connection with the natural world (fast, slow, full, empty, bounding, collapsing) but is primarily concerned with the number of beats and their rhythm. The music of beats and rhythms is considered to be ‘heard’ better by machines so that heart monitoring, such as by the ECG, is taken as the ultimate authority on the patient’s situation. The technical language associated with this type of investigative scrutiny is accorded greater credibility than the nature-terms used in examination – the precision of identifying a ‘variable PR interval’ is preferred to physical detection of an ‘irregularly irregular’ pulse.
In ancient and traditional medicine, the ultimate diagnostic authority is the practitioner and the key reference point is nature, whereas in biomedicine, technology has become both authority and reference point. This is unsurprising given that the internal geography of the body can be exquisitely revealed by technology that penetrates more deeply than the human senses. MRI scanners can display the no-longer-hidden body in fine slices of digital meat. In the face of such astonishing capacities, continuing to bend the human senses to dimly perceive what the machine can so lucidly expose may seem not even quaint but wilfully perverse, and perhaps irresponsible. Yet the risks and costs of high-tech investigative techniques prohibit their widespread use to varying degrees depending on the affluence, healthcare politics and level of techno-centrism of particular cultures. Physical examination remains, in conventional medicine, at least as a handmaiden to clinical investigation, used (along with the case history) to screen and decide whether the risks, inconvenience and costs of investigation should be borne.
The shift of the locus of authority and reference in medicine from practitioner/nature to technology is part of such a movement in cultures generally. Innovations in technology shape the way in which the body is discussed and perceived, moving away from organic metaphors to mechanical ones (e.g. that the eye is like a camera or that the brain is like a computer). The increasing familiarity with, and emphasis on, technology does not represent a smooth and linear transition from the natural to the technical however, rather there is interplay between the two themes as opposed to a straightforward rejection of one in favour of the other. The history of what is known as the ‘annual physical examination’ or ‘periodic health examination’ provided to adults in America reflects the complexity of this relationship (and the complex relationships between case-taking, physical examination and clinical investigation).
The idea of providing periodic health examinations to ‘apparently healthy persons’ (Dodson 1925) crystallized in the 1920s and began to be variably implemented from that time. The format of the examination differed across America at the outset and has never been universally standardized. An early example of a ‘Guide Card’ for the examination is shown in Figure 6.1. This shows that the ‘examination’ combined history-taking (including focus on diet and work-related issues) with a mix of physical examinations and minimal reference to ‘laboratory tests’ ‘when indicated’ (Thomson 1925).
Prochazka et al. (2005) showed that the annual physical examination is today based largely on a range of blood tests (such as lipid panel, liver function tests, thyroid and complete blood count) and urinalysis as well as height, weight and blood pressure measurements and cervical smears and mammograms in women, with these ingredients being variously combined. Investigation has moved from an optional extra in the 1920s to occupy centre stage in the early twenty-first century. The authors questioned public and practitioner attitudes towards the examination and contrasted their background understanding that: ‘Current evidence does not support an annual screening physical examination’, with their study findings that ‘a relatively high percentage of the general public desired an annual physical examination’ and that most primary care physicians believe that such an examination ‘detects subclinical illness’. Interestingly, while 63% of physicians believed that the examination was of proven value (contrary to the evidence), ‘94% believed that an annual physical examination improved the physician–patient relationship and provided valuable time for counselling on preventive health behaviours’. This latter belief returns us to Greaves’ insight that, beyond diagnosis, physical examination ‘would seem to have an additional significance’ and adds to our earlier discussion of the extra dimensions of the examination.
The regular laying-on of hands and stethoscope (and maybe phlebotomy needle, too) is not a needless ritual if it fosters trusting clinical relationships and ensures that patients receive effective counselling and preventive interventions.
In an accusation that could be levelled more generally at the change in emphasis of conventional medicine as a whole over the course of the twentieth century, Han (1997) contends that the American annual physical examination has changed:
… from a comprehensive fact-finding exercise aimed at detecting physical defects and amassing the available techniques of history-taking, physical examination, and laboratory technology into a parsimonious collection of tests for the early diagnosis of disease.
He gives two perspectives on the reasons for this change, a ‘conventional view’ and an ‘alternative argument’. The conventional take accounts for the change as reflecting: ‘a positive evolutionary advance in knowledge – a replacement of naïve enthusiasm with scientific scepticism’. Whereas the alternative perspective argues that: ‘shifts in the acceptance and content of the periodic health examination were tied to fundamental changes in the objectives that the examination served’. These objectives have included: ‘scientific knowledge, economic savings, professional empowerment, the physician-patient relationship, data collection, satisfaction of patient demand, and administrative efficiency’. The appreciation and practice of the consultation, in all its aspects, continues to be shaped by these influences.
Even less is known about the same issue in contemporary herbal practice, although this fact is possibly less surprising given the very small size of the profession and the lack of a research culture in herbal medicine as in other modalities classed within the CAM bracket.
In response to research suggesting that there are ‘widespread deficits in the physical examination skills of practising physicians’, Ortiz-Neu et al. (2001) investigated the competency of 3rd-year medical students in conducting cardiovascular examination in eight medical schools, concluding that their results suggested: ‘fundamental inadequacies in the current paradigm for teaching physical examination skills’. Other authors (such as Bordage 1995) have expressed concern regarding the decline of the emphasis on, and competence in, physical examination skills on the part of medical students and physicians. My experience, as a teacher and examiner working with herbal medicine students and practitioners suggests that physical examination skills are often inadequately taught (teaching is frequently partial, rushed, with insufficient time allowed for practise); that a desirable level of examination-related knowledge and fluency is rarely achieved by the time of the final clinical examination; and that herbal practitioners soon reduce their use of physical examination techniques to a narrow base when in practice.
The level of competence in physical examination skills is therefore a concern in both conventional medicine and phytotherapy but addressing this is hampered by further concerns that call into question the reliability and validity of physical examination in the first place. If physical examination is unreliable, then why should efforts be made to improve the teaching and practice of it?
Physical examination is a largely subjective art and a number of papers have found poor interexaminer (or ‘interrater’) reliability in conducting particular examination techniques (such as Yen et al. 2005, looking at abdominal examination of children), while others have found a good degree of reliability (such as Weiner et al. 2006, studying examination of chronic lower back pain). One issue here has to do with the degree of expertise possessed by the examiner. For example, a skilled examiner who is able to help patients relax and who uses ‘reinforcement’ (a technique that causes momentary relaxation of the body part being examined) in testing reflexes is more likely to be able to elicit them.
A further concern regarding the value of physical examination is raised by studies that have shown certain investigative techniques to be superior to examination techniques in particular cases. For example: Kolb et al. (2002) found that combined mammography and ultrasound was superior to palpation in detecting small breast cancers; Spencer et al. (2001) showed that the use of a portable echocardiography device was more effective than physical examination in assessing the heart in cardiovascular patients; Wipf et al. (1999) showed that chest examination was unable to confirm or exclude the diagnosis of pneumonia and that X-rays provided the best diagnostic test. None of these studies called for the abandonment of physical examination however, some (e.g. Spencer et al. 2001) have drawn attention to the areas of strength as well as weakness for examination techniques, but all have suggested the need to become more aware of the accuracy and reliability of physical examination. Other studies have clarified the value of examination. For example, in a small study, Nardone et al. (1990) explored the value of physical examination in suggesting whether patients had anaemia. They looked at pallor in the conjunctivae, face, nails, palms and palmar creases and concluded that ‘the absence of pallor does not rule out anaemia’; that examination of nailbeds and palmar creases was of no value in assessing anaemia; and that if combined pallor of the conjunctivae, face and palms was found this did indicate the presence of anaemia.
In the foregoing discussion, we have drawn on the developing evidence base for physical examination, which has both raised and addressed concerns regarding the credibility of this part of the consultation. An influential paper in developing the notion of evidence-based physical examination was that of Sackett and Rennie (1992), which justified and introduced a series of articles in the Journal of the American Medical Association (JAMA) that scrutinized examination methods. The authors first noted the value of physical examination in:
‘But’ they cautioned, ‘there is a science to this art of medicine’, and the time had come for a more rigorous evaluation of physical examination to take place. The old physical examinations should be treated in a way similar to the new diagnostic procedures, where:
… it is now commonplace to see the advocacy of (such) procedures supported by their repeated, independent, blind comparisons with reference or ‘gold’ standards … No laboratory or physiologic test deserves adoption until it has been so tested.
Physical examination then, was like a dusty old attic where treasures might be discovered among a lot of rubbish; it stood in need of a good sorting out. JAMA was to undertake this task by publishing ‘regular reviews of the precision and accuracy of specific elements of the clinical examination’, despite the risk that, in doing so: ‘Some hallowed elements … justified by time and authority, may go down in flames … Many more … will be placed on probation because their precision and accuracy are simply unknown …’.
Subsequent JAMA articles appeared under the banner of ‘rational clinical examination’, eventually leading to the publication of a book with that title (Simel & Rennie 2009). An earlier attempt at providing a manual of Evidence-based physical diagnosis was made by McGee (2001). The work done by these authors in increasing the scrutiny applied to physical examination amounts to an effort to save it, as if it were an endangered species, in the face of a movement that considers, as McGee put it: ‘that physical diagnosis has little to offer the modern clinician and that traditional signs, although interesting, cannot compete with the accuracy of our more technologic diagnostic tools’.
Phytotherapists need to engage critically with the revision of the physical examination repertoire that is taking place via the evidence-based approach – taking its lessons and insights on board but challenging it where it reduces physical examination to a merely diagnostic act. The human dimensions of the examination need to be remembered.