The Laying on of Hands Is Both a Diagnostic and a Therapeutic Act

by

Dr. Alan Rapoport, MD

I had just thoroughly examined an older snowbird, visiting our tropical island, for a complaint about (fill in the blanks). Afterwards we sat at my desk and he said: “doc I’m taking you back home with me; my doctors don’t examine me anymore; no one touches me.” I smiled in recognition of an old litany. I looked the patient in the eye and said, more or less, Harry I don’t want to believe you; it is a stain on the profession, but I’m forced to believe you because I’ve heard it so many times. He went on to say “my doctor communicates with his laptop more than with me”.

In the office most people, I am told, have the blood pressure checked in one arm only; but on the first visit we check both arms. If patient is taking antihypertensives or if the blood pressure is above 120/80 we check for orthostatic hypotension after standing 2 minutes because a significant drop may indicate secondary hypertension, especially pheochromocytoma, or excessive blood pressure medication. I then check the blood pressure in one leg with the patient supine looking for coarctation of the aorta. Customarily I listen to the heart in 4 positions, 2 seated, 2 supine. There is always someone with a murmur out there who doesn’t know it. Sooner or later some of these folks need valve surgery. I do all this because this is what we are taught during our early days and over the ensuing years even after training. Is all this passé? My patients tell me that their GYN’s rarely do a rectal. One colleague told me “Rapoport we let you internists do the rectal”. I understood; the ladies don’t like it at all, who does? When I used to see patients as a social security examiner I would check the ocular fundi. I would often ask the diabetics if their MD’s did so. Most said that the PMD did not check the fundi and, alas, many said that the endocrinologist didn’t either.

The Medicare Electronic Health Record Incentive Program (EHR) notified me December 29, 2016 that I was to be penalized for not having an EHR. I send the colleagues and consultants a lengthy detailed typed note and hope for feedback. To my joy, a copy of the EHR sometimes shows up. The few EHR reports I have been able to review have led to some observations. They are dense with lots of verbiage. However, there is less than meets the eye. Details I have supplied about the present illness (PI), past medical history (PMH), social history (SH) and even physical examination (PE) are not incorporated into the report. The PI and PMH are very terse. The cardiac exam may fail to mention the location of a murmur, its quality, its radiation. The summary may be a few words. One doesn’t have a sense that the writer has considered the differential diagnosis. Does the Medicare Electronic Health Record Incentive Program care about content? Did they never hear the famous dictum GIGO (Garbage in/Garbage Out).

Evidence based medicine has challenged the value, to the patient, of the annual physical exam and the routine vaginal exam and many other things we used to take for granted. So when in doubt I pull out a 64 page monograph given to me probably in the early 1980’s by the A.H. Robins Company titled G.I. Series – Physical Examination of the Abdomen.⁽¹⁾ On page 13 we read in Chapter 2, “PALPATION   Inspection, palpation, percussion, auscultation – these are the four most significant sensory means for determining diagnostic clues. Frequently, findings elicited through these basic steps of physical diagnosis are the only ones required to make a diagnosis– or, at the very least, they yield information that helps determine the next step toward making a definitive diagnosis. In Chapter 1 Inspection, consideration was given to the diagnostic information obtainable through viewing the patient – as a person and as a human body, with landmarks of significance in physical diagnosis. In Chapter 2, Palpation, attention will be focused on perhaps the most important element in physical diagnosis of the abdomen – touching. The value and significance of the ‘laying on of hands’ has become so much a part of the language of medicine that one tends to take for granted this basic art. Yet its meaning to the patient, to the physician and to the practice of medicine is unique, profound and unparalleled. For all patients, everywhere, examination means being touched, with the physician feeling ‘where it hurts’. This is particularly true of patients with gastrointestinal disorders, disorders frequently involving a strong emotional component. Gastroenterologists recognize – as do other physicians that ‘gastroenterology as a clinical endeavor continues to demonstrate that there can be no mechanical substitute for nearness to the patient. The specialty continues to demand total-patient evaluation and treatment.’ For the G.I. patient, coming to the physician urgently seeking relief from real or imagined problems, the examination itself is the first step in the treatment program. And ’the laying on of hands’ is both a diagnostic and a therapeutic act.”

But how do we look upon examining the patients in this age of Medical Taylorism and the 20 minute visit so eloquently decried by Hartzband and Groopman.⁽²⁾ The final straw is the amusing/tragic text message making the rounds which was sent to my cellphone the other day showing a grave stone which read:

If we don’t do routine physical exams, don’t do routine vaginals, don’t do rectals, don’t check ocular fundi, don’t look for orthostatic hypotension, don’t touch the patient, how are we to acquire and maintain the skills of physical diagnosis. Are these still important in this era of ubiquitous, essential, highly remunerated advanced imaging? In the future will we be replaced by skillful and attentive PA’s and nurse practitioners? They are waiting in the wings!! Tell Washington, the Center for Medicare and Medicaid Services (CMS), the insurance industry and the medical schools to encourage skillful physicians to practice medicine as they learned to do… I’m not holding my breath.

References:

1. G.I. Series  Physical Examination of the Abdomen, A.H. Robins Company, undated, unauthored monograph, page 13
2. P. Hartzband & J. Groopman, Medical Taylorism, New England Journal of Medicine, January 14, 2016, Vol. 374, No. 2, page 106-108.

Biography