What are we to learn at the bedside? A re-examination of Verghese's essay "Culture Shock"

Abraham Verghese's essay "Culture Shock" (pdf) made a lasting impression when I came upon it last night during a quiet period at work. He writes beautifully about the real patient, with all his spots and signs - as opposed to what Verghese calls the "iPatient," the simulacrum found inside the electronic medical record but nowhere else.

I do realize that we residents, no matter where we train, hone our skills on the iPatient's indices ("The iPatient's blood counts and emanations are tracked and trended like a Dow Jones index, and pop-up flags remind caregivers to feed or bleed") while getting ever farther away from the bedside physical exam done on the real patient. This article makes as powerful a case as any I've read for the re-centering and re-honing of my skills, and it comes at just the right time, when I have the chance to make a transition to be the kind of doctor I want to be. 

But Verghese is confused in his defense of the physical exam - he doesn't know what rationale he wants to focus on, or how he feels about physical diagnosis as justified (or questioned) by evidence-based medicine. Here he is in one place:

If one eschews the skilled and repeated examination of the real patient, then simpl diagnoses and new developments are overlooked, while tests, consultations, and procedures that might not be needed are ordered.

This is the argument from efficiency, or maybe from diagnostic rigor - exceeded somewhat by Verghese's clear affection for the physical exam as a pedagogic and maybe, even, an esthetic, cultural, and moral tool. But it's not clear whether Verghese believes that the physical exam does improve diagnosis or efficiency. Just paragraphs later, Verghese takes another turn:

Younger physicians often argue that physical signs lack an "evidence base." Clearly some signs are helpful, some are not, and we need continued study in this area. But recognizing erythema nodosum or decreased breath sounds and dullness over a larg pleural effusion is worthwhile in and of itself.

The physical exam's actual use in diagnosis is again feinted toward, but without making a real case one way or the other ("we need continued study in this area," the academic physician's classic copout that I know I use at the end of every article I write).

Near the end of the essay, and most confusingly, Verghese takes yet another tack when describing with understandable pride the teaching of the bedside physical exam he coordinates with his chief residents:

We teach that physical findings should be considered biomarkers, phenotypic markers. ... An enlarged spleen, Roth's spots, a Virchow's node, and jugular venous distention are all biomarkers that should be factored in with the high calcium level, the abnormal MRI, and other data to arrive at a true picture of the patient. Failure to recognize these biomarkers is an oversight akin to not seeing a key laboratory value in the chart.

But this comparison is double-edged. If a finding on the physical exam is like a biomarker, then it is like any other diagnostic test, which can be ignored, re-interpreted, or even not tested at all based on the prior probabilities the physician approaches the patient with. Perhaps - given the patient - I might prefer the information given by X-ray to my own physical exam. Or maybe, given the vagaries of varying echocardiography reads, I might privilege my own cardiac exam.

This is why I find Verghese's essay, though moving and personally challenging to my own too-ingrained love of EHRs, to be ultimately unsatisfying. If medicine is a culture, it changes. If the physical exam is to be a practical part of the diagnostic art, and not a relic, it too must change. Let's find out which parts of the diagnostic exam work, and why. We know that no physician does the "head-to-toe exam" for more than a fraction of his or her patients, so which parts should be done when? When is it useful to look for Roth's spots as a diagnostic adjunct rather than as a fascinating bedside pedagogical tool of limited clinical import? (Probably rarely.) Given our limited time with patients, should we not build rapport and understanding by asking more detailed histories at the bedside, rather than indulging in percussion of parts which have no diagnosis to yield up? 

I take Verghese's wisdom and his eloquence but I look for rigor elsewhere, trying to spend my time with the patient in ways that build our therapeutic relationship and find a true diagnosis efficiently.