Every Patient Tells a Story (10 page)

“First you inspect,” she told us. “The breasts should be symmetric.” She raised her hands above her head, and her breast stretched upward as well. Then she placed her hands down on her hips, spreading her elbows wide to stretch the chest muscles and the breasts. “This gives you a chance to see any abnormalities that affect the shape of the breast or the texture of the skin.”

As she ran through her orderly presentation the tension in the room began to fade. Her matter-of-fact demonstration communicated an ease with her role as a patient and her expectations of us as doctors. I realized later that she was not only teaching the basics of the breast exam, she was demonstrating
a technique we could use in our own encounters to bring a naturalness to the awkward physical intimacy between a doctor and a patient.

“I’m going to demonstrate how to examine my breasts and then each of you will do it.”

We crowded around the table as she lay with one hand over her head and the other performing the examination.

“Start at the midline. Use the pads of your fingers. Press them lightly on the breast and make a circle. I like to anchor my fingers to each spot and move the skin along with my fingers so that I know that I’m examining the same spot. You do that three times at each spot, each time applying just a little more pressure so that you can feel all the different structures under the skin.”

We watched with interest as she repeated this motion up and down her chest in overlapping stripes from her sternum all the way over to her side and up into the dome of her underarm.

“Now you try it.”

As I stepped up to the exam table I could feel my discomfort reemerging. I rubbed my suddenly cold hands together, trying to coax blood into icy fingers, then placed them on her chest. Her skin was warm and I could smell the fragrance from the soap or deodorant she’d used that morning. Her professional but casual tone kept me focused on the medicine at play here and not the intimate zone that she and I had suddenly entered.

“Follow the clavicle over to where it meets the sternum,” she instructed me. Her voice was patient, comfortable, completely relaxed. I moved my fingers self-consciously, in an awkward circle over the skin, bone, and cartilage. Next to the sternum a thin film of fat overlies smooth, tough muscle and ribs. Further down the chest the layer of fat gets thicker at the outer region of the prominence we recognize as breast. It wasn’t until I started the second stripe that I encountered the fingerlike irregular densities of the glands themselves, pointing inward to the nipple like the spokes of a wheel. As I made my way across the breast, images from my anatomy book depicting these structures I could only feel flooded my mind, like aerial photographs providing landmarks and explanations of the terrain beneath
my fingers. The area directly under the nipple dips like a soft well into this dense tissue; I could picture the ducts, too fine to be felt. Below that, I felt a saucer, a hockey puck of thick consolidated gland too closely packed to be individually distinguished.

As I worked my way across her breasts, she offered advice and encouragement.

“You can use more pressure than that if you need to. It doesn’t hurt me. Use your other hand to stabilize the breast.”

I covered her chest with the lines of circles, working to make sure I could feel every structure below the skin from as many angles as possible. I thanked the instructor and gratefully stepped back from the exam table as the next student stepped forward. I watched as she coaxed and encouraged my three classmates through the exam and reviewed the process in my head from the safety of my chair.

A couple of years ago I moved my practice from one office to another. As I reviewed the charts of my relocated patients, transferring data from old to new, I noticed that although I had done a pretty good job in making sure that my patients got their recommended screening tests, I hadn’t done nearly as well on the hands-on component. Women should have a breast and pelvic exam performed annually, I was taught. Men over fifty should have a yearly rectal exam to look for prostate cancer. I saw that my adherence to those guidelines was pretty spotty. I was surprised by this oversight, but the trend was too strong to deny.

I puzzled over this. How could this happen? Some of it was a systems problem. In my old office there was no simple way to keep track of routine exams. To find the last exam I’d have to page through the last year’s worth of visits to see where I’d documented the results. And yet regular cholesterol tests were there. My patients over fifty had colonoscopies ordered or at least discussed. No, it was the breast exams, pelvic exams, and prostate exams that were missing. And I realized that despite the years of practice and the mastery of technique, I still found these exams uncomfortable to perform.
On some level, I was still that medical student, reluctant to touch another person’s private places.

I’m not alone in this. There’s not a lot of data on this issue, but what’s there suggests that more of us are sending our patients for the screening test and dispensing with the hands-on component. In a study published in 2002, of the 1,100 women who went for annual mammograms in one facility over the course of a year, only half reported having had a breast exam done by their physician—ever. And while rates of mammography have increased over the past twenty years, rates of physician breast exam have declined.

Is that all due to the awkward intimacy of the exam? Probably not, though research has shown that it plays a role. Instead, the development of newer and better technologies—the mammogram, ultrasound, most recently the MRI—has caused doctors to doubt the value of what their hands can tell them. Why deal with your own embarrassment, the possibility of patient embarrassment, and the difficulty of interpreting the fuzzy pictures generated by touch when a study can show you the inner structures of the body with more precision and accuracy?

Why indeed? I’ll explore some of the answers to this increasingly urgent question in the next chapter.

CHAPTER FOUR
What Only the Exam Can Show

A
s the skills required for an expert physical exam have become more and more rare, both among medical students and among practicing physicians, what has been lost? Among doctors, this is a topic of passionate debate.

On one side are those who argue that the demise of the physical exam is a natural consequence of progress. They say that the exam is just a charming remnant of a bygone era—like cupping (attaching warmed cups to the skin until blisters are formed) or bleeding or mustard plasters for colds—now replaced by an ever enlarging menu of technologies that provide better information with greater efficiency and accuracy. Affection for this discredited practice is characterized as pointless and sentimental.

On the other side are the romantics: doctors who see the physical exam as part of the long tradition of caring in medicine and cherish the profound connection between doctor and patient when linked by a well-placed hand and a warm heart. They see those who think otherwise as soulless technicians.

In the middle are the rest of us who simply want to understand what’s been lost. How large a role did the physical exam once play in making a diagnosis? What are we missing in the modern version of medicine that somehow seeks to manage without it?

——

Steven McGee, a mild-mannered man with a serious face, an FM radio voice, and a scholarly passion for the physical exam, has blazed a rational trail deep into that middle ground. As an internist and a professor of medicine at the University of Washington, he embraces technology but also believes that the physical exam has uses that machines cannot replicate. McGee’s research is an outgrowth of his own experiences in medicine, and his book,
Evidence Based Physical Diagnosis
, outlines the evidence for the utility of the physical exam in the age of high technology.

When I spoke with McGee about his work, he was eager to tell me about examples from his own experience of medicine that proved to him the fundamental importance of examining the patient. He recalled a particularly dramatic case that had occurred just a few weeks before we spoke.

McGee and his team of residents and medical students were called to see a patient on a surgical floor. The patient had come to the hospital for the excision of a skin cancer on his ear. That morning he’d developed severe abdominal pain, and the plastic surgeons had asked them to help figure out what was going on.

Michael Killian, a thin elderly man, lay on the bed with his eyes wide open, moving restlessly as if he couldn’t find a comfortable position. He muttered incoherently as he shifted awkwardly across the bed.

The resident introduced himself to the distraught patient and immediately began asking questions. “I don’t know. I don’t know. I don’t know,” was his only answer. It quickly became clear that the elderly man was too confused to provide any details about his pain. He could tell them his name. But he didn’t seem to know that he was in the hospital or why. All he could say was that he hurt. When the resident asked if he had pain in his belly, he started his litany once more: I don’t know, I don’t know.

His skin was pale and littered with scaly patches of red, evidence that he’d spent too many hours in the sun. The ear that had brought him to the hospital in the first place was enlarged and distorted by a raised red and scaly lesion at the tip. His unshaved cheeks were gaunt, his cheekbones sharply defined, his eyes seemed focused on something in the room no one else could see. A fringe of white hair was well cut but uncombed. His skin was cool and damp with sweat. It was difficult to examine him because of
the constant restless movement. His heart was fast but regular. So was his breathing. When the resident moved to examine the patient’s abdomen, he jerked away. “No. No. No. Don’t touch me.” The distant eyes were now back in the room, glaring at the young doctor. The patient waved his arms in a way that suggested that no means no. The doctor quickly pulled back.

“No. No. No.”

The resident leaned down and began to speak in a quiet voice to the distressed man. “I know you are in pain and I want to help you. But in order to help you I need to touch your stomach. I won’t hurt you.” The soothing tone eventually quieted the suffering man, though he continued to shift his position on the bed, as if the soft mattress had been replaced by a bed of nails.

As the resident reassured the confused and frightened man, McGee gently placed his hand on the upper left side of the man’s abdomen. He felt an unexpected resistance in the normally soft region of the belly and quiet steady pulsations. He placed his other hand over the man’s navel. A soft mass throbbed beneath his fingers, pushing his fingers away to the right. And that told him everything he needed to know.

“Call the surgeons,” McGee told the resident. “This man needs to go to the OR. He’s got a rupturing aortic aneurysm.”

The aorta is the vessel that carries blood from the heart to the rest of the body. Patients with hardening of the arteries and high blood pressure—like this man—can develop areas of weakness in the normally thick muscular tubing, and the stress of this high-pressure system can cause these weak spots to balloon outward, forming a pulsating bulge in the abdomen. When the balloon gets large enough, the muscle wall becomes dangerously thin and it’s at risk for bursting. The excruciating pain and the restless movement were classic for a tear in the now delicate muscle wall, and the huge pulsating mass clinched the diagnosis. Three quarters of all patients who suffer this dire event die either on the operating table or on their way there.

The vascular surgeons were paged and the patient was taken to the OR, stopping only briefly at the CT scanner to verify the diagnosis. Defying the odds, Mr. Killian survived the surgery, his life saved by a simple touch.

As compelling as any individual case may be, in medicine, if you want
proof you need studies. And McGee has spent his career investigating and tabulating the accuracy of individual components of that endangered art, the physical exam. His results have managed to anger folks on both sides of the debate. Some well-known, frequently taught parts of the physical exam have turned out to be virtually worthless—listening to the lungs will rarely help a physician decide if a patient has pneumonia. Others, when done well, have shown themselves to be as solid and reliable as the tests we use to confirm our diagnoses. In the hands of experts, a cardiac exam can identify problems in the valves of the heart almost as well as the echocardiogram. It’s essential to know how well each of these individual tests performs.

But this research still leaves the big question unanswered: is there any evidence that this old-fashioned practice really makes a
difference
in how patients do? There is surprisingly little research on this. Several now classic studies done in the 1960s and 1970s tried to assess which tools are most useful in helping doctors make a diagnosis. In these studies the most important tool was the simplest—doctors were able to correctly diagnose patients’ illnesses in most cases just by talking. The patient’s story contained the diagnostic tip-off up to 70 percent of the time. Doctors are told repeatedly in medical school to listen to patients and they will tell you what they have. These studies prove the wisdom of this advice.

But what about the physical exam? In these same studies, when you looked at just those patients whose story didn’t provide the answer, the physical exam led to the right diagnosis about half the time. High-tech testing showed the way in the remaining cases.

Of course, testing has changed a lot since those studies were done. A more recent study, done by Brendan Reilly, a head of clinical medicine at Weill Cornell Medical Center, looked at this question in a different way. Reilly was asked by one of the residents he teaches how important the physical exam was in making a diagnosis. Reilly searched the medical literature for an answer. When he couldn’t find a good answer, he designed his own study.

In a teaching service like his, patients are seen first by the internal medicine residents and then are examined and evaluated separately by the attending physician. The residents and the attending swap the information
they collected independently to figure out a diagnosis and care plan. Reilly reviewed the charts of all the patients he had admitted to the hospital with his team over the previous six weeks, looking for any case where something he found on the physical exam had changed the diagnosis and the treatment of patients under his team’s care.