Commentary

Examine the patient, not just the evidence


 

References

Dr. Hickner’s editorial “Let’s talk about the evidence” (J Fam Pract. 2015;64:337) struck a chord with me. I am very supportive of evidence-based medicine (EBM), but am often dismayed by the lack of humility expressed by EBM leaders, including the US Preventive Services Task Force. We have so little evidence about much of what we do in family medicine, and most evidence comes from studies that are narrow by nature (reductionist research).

Increasingly, I see patients become annoyed and critical of physicians who do not examine them.

For example, doing a physical exam is part of “laying on of hands” that is part of the art of medicine. Abraham Verghese, MD, MACP, has written and spoken about the importance of examining the patient and not just depending on data.1 Yet elements of the physical exam, such as the pelvic exam example Dr. Hickner mentioned in his editorial, do not stand up well in EBM due to a lack of diagnostic accuracy. I’ll ask this: Who has studied the harm that may be caused by not examining our patients?

My physical exam “ritual” takes less than 10 minutes, and the value in the relationship I have with patients is more than a diagnostic exercise. Increasingly, I see patients become annoyed and critical of physicians who do not examine them.

Joseph E. Scherger, MD, MPH
Rancho Mirage, Calif

1. TED Talks. Abraham Verghese: A Doctor’s Touch. TED Web site. Available at: http://www.ted.com/talks/abraham_verghese_a_doctor_s_touch. Accessed July 20, 2015.

Author’s response:
Dr. Scherger makes an excellent point about the importance of physical touch for the doctor-patient relationship. The question is: What touching is appropriate? In my own experience, I have noticed that most—but not all—of the women I see are quite relieved that they don’t need yearly pelvic exams, and women I see for pap smears do not seem put off if I do not do a bimanual exam. The data are actually quite strong that routine pelvic exams in asymptomatic women lead to more harm than good. They uncover way too many false positives and almost no true positive findings, leading to unnecessary testing and treatment.1,2

John Hickner, MD, MSc
Chicago, Ill

Dr. Hickner is the editor-in-chief of The Journal of Family Practice

1. Ebell MH, Culp M, Lastinger K, et al. A systematic review of the bimanual examination as a test for ovarian cancer. Am J Prev Med. 2015;48:350–356.

2. Well-woman visit. Committee Opinion No. 534. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2012;120:421-424.

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