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Welcome to third world medication.

Here is an article by a doctor:
When All Else Fails, Examine the Patient?

It’s a favorite tongue-in-cheek line I used when I was a resident on morning rounds with anxious interns and students at my side. After spending the entire night on our feet, we heard exhaustive histories, presented lab results as long as a ticker tape, and proudly displayed X rays and CTs while fighting sleep in the soft glow of the radiology board. Occasionally, I’d ask a salient question, “But what did their physical show?” Sometimes it was obvious the examination was the more cursory portion of the presentation.

I’d like to share a few scenarios that occurred in the short space of just a few days in my private practice to make the point that the physical exam is on the endangered list. These scenarios say a lot about what’s happening with modern American medicine, cardiology included. Please don’t kill the messenger.

Scenario 1
“I’m here for a second opinion with my mother because the last three times we’ve seen our cardiologist, he never once touched her,” lamented the concerned daughter with a smiling geriatric mother at her side. “How does he know what’s really going on without listening?”

Scenario 2

“I saw my doctor the other day. He used to give me a thorough exam. He even found my prostate cancer a few years back, but this doctor that I saw the other day—he’s not the same Dr X,” said the patient. “He even mentioned that I should have blood work now and then come back in four months and said we’d ‘do more blood work,’ but he didn’t even use his stethoscope and I’ve not seen him in months. I don’t think I’m going back.”

Scenario 3
A beautiful, blonde, statuesque patient came to my office for near syncope. Her orthostatic BP was normal. Her labs were normal. The Holter from another facility was benign. Cardiac exam was completely normal, but when I stretched her out on the exam table, her abdomen was rock hard. For all the world, in that position, I thought she was nine months pregnant.

“Are you pregnant, by any chance?” I asked.
“That would be impossible,” she replied. “I’ve had a tubal.”
I actually placed my arms around this gigantic tumor as an OB would do to query for fetal position. “I think you have a very large tumor in your abdomen,” I said, and sure enough, on CT, there was a 16-cm mass accompanied by multiple tumors crowding her entire abdomen.

But, Wait . . . It Gets Worse

She developed chest discomfort a couple of weeks after a completely normal stress cine was performed for preop assessment. She was out of town, and I directed her to go to a local ER. I received a phone call from a healthcare extender, who at the time of our communication (which I postulate should have occurred after a physical exam) was couched in such a way that they seemed to have no knowledge of the issue at hand. I patiently explained the case and said, “Here, take my cell number and ask anyone who would like a discussion to call me. Her stress exam looked great, but I’d check her troponin and if she has ongoing pain, you may even have to take a look at her coronaries because she’s a preop patient. My bet is that she is having pain from a very crowded abdomen.”

But, Wait . . . It Gets Even Worse

The following morning I received a phone call from an intern who said, “Your patient has this odd abdominal pain,” then hesitated as if clueless, to which I impatiently replied, “Yes, and if anyone, anyone, would put their hand on her abdomen, she has a tumor the size of a large watermelon that spans from her symphysis pubis to nearly her diaphragm. It is likely compressing her vena cava in a seated position, causing presyncope.

It’s crushing her bladder such that she has to urinate every hour on the hour all night long and she can no longer have intercourse with her husband without severe pain. You might want to examine her abdomen. I think you’ll be impressed!” and then hung up.

I am not a perfect examiner or a perfect physician. None of us are. I even find things on a second exam that I have missed, like a soft carotid, an abdominal bruit, or a murmur that I’m certain didn’t just occur yesterday, but the point is this: If I don’t listen or touch or feel, I’ll never find it. I’m alarmed because these scenarios are cropping up more often, and harm is coming to the patient population more commonly because of it. Doctors are busy. Constraints on time are greater due to the changing healthcare climate that invites greater revenue if less time is spent in the room with the patient to allow more time to see others. We are relying on healthcare extenders more often, who haven’t spent as many years training in physical-examination technique (hold up! I’m not insulting anyone, just stating the obvious and at the same time, I acknowledge that some patients are examined more thoroughly by healthcare extenders than some doctors and sometimes it’s the only exam they get).

We Are Cardiologists, but We Are Also Internists
It’s okay to examine the patient, find a melanoma, diagnose walking pneumonia, refer a hammer toe for surgery, get a gall bladder removed, discover an uretovesciular tumor that is causing referred chest pain due to a complete ureteral obstruction—these are actual scenarios that occurred in our cardiology office over the past few months.
Some provider somewhere in this disjointed loosely woven patchwork quilt of American medical care must own the process. Someone must declare “the buck stops here” when a patient who has exhausted several avenues presents to us in desperate need. I think the best attitude is this: “If I can’t find it, I will find someone who will,” and then of course, when all else fails, examine the patient.