"The Fading Art of The Physical Exam"

NPR just ran a piece on how physicians aren't examining patients anymore. It's true, even in an environment like the intensive care unit where small details can make or break you. When a physician follows a patient in the ICU, or even on the general floors, they typically don't do daily evaluations. It's even rare to see them use their stethoscope. Rather, they depend on the nursing assessments. They assume that the nurses would tell them if anything is amiss.

Of course, the piece centers on how diagnostic testing is replacing physical examination. Diagnostic testing is a little more glamorous and newsworthy - it's expensive, technological, and sexy.

"We're now often doing expensive tests, where in the past a physical exam would have given you the same information," says Jason Wasfy, a cardiologist-in-training at Massachusetts General Hospital in Boston.

As a result, many doctors are abbreviating the time-honored physical exam — or even skipping it altogether.

The missing piece is that patients aren't being taken care of by expensive testing. The radiology department does not follow your patient for you on a daily or hourly basis. The time-honored physical exam is skipped partly because you can just run tests instead, but mostly because nurses are during frequent assessments.
Doctors can't auscultate chests as well as they used to because they can just look at a chest x-ray instead, but also because the nurse is going to report on any problems with their oxygenation status, with their breathing efforts, with how their lungs sound, and with what treatments are working or not working.

In fact, the situation is a little ironic: because nurses can be sued for not telling the doctor pertinent information, and because doctors can (and do) defend against lawsuits by claiming nurses did not tell them what they needed to know, doctors can safely assume that nurses are evaluating their patients for them.
I know, that's just more physician-bashing. Well, not really. I actually don't mind that they trust our assessment skills and our judgment. We're with the patient all day long, and they have forty patients to see that day, so they need to listen to us.

What about when the doctors sees you directly in the office? The article goes on to claim that "Even when doctors go through the motions of doing a physical, their diagnostic skills aren't what they used to be" and refers to a test where doctors missed a large number of defective heart sounds. I think this is because physicians receive their training in the hospital, where they can, as I said, rely with the nurse's assessments and diagnostic tests to do their evaluations for them. It still goes back to the hospital nurses.

Like I said, I like the autonomy and authority this gives to the RN. And if the news isn't aware of it, that's fine. But I have to admit it's a little worrisome. If you don't have a thorough nurse, and your physician just glances in at you and reviews the chart, then something could be missed until it causes such a big problem nobody can overlook it.

The fact that your healthcare system can't "waste" the expensive time of physicians on general physical exams for everybody means that it needs really, really good nurses.