Mere Competence

October 15, 2017

Hi everyone,

I'm a physical exam skeptic, but not in the way you'd think.  I believe in exams, but when someone claims a patient has no adenopathy, no JVD, and no murmurs, I'm filled with doubt, particularly when a history signals findings we should be able to feel, see, or hear.  Experience tells me that SBOs cause distended abdomens and interstitial lung disease leads to rales.  Competent exams should be revealing, but incomplete or superficial ones are useless.  So I'm skeptical.

Compared to experts examiners, I'm merely competent.  But I carry a faith in the exam that was cultivated during training, when it was no great accomplishment to hear an S4, spy distended neck veins, or tap out an effusion before plunging a needle into someone’s chest.

Over the course of my career, game changing exams have seared memories into my brain.  As a third year student, I found an occipital lymph node on a woman with an FUO, which led to a biopsy and diagnosis of military TB.  As a resident, I saw a Penn undergraduate with a sore throat whose pulse pressure seemed too wide.  A diastolic murmur suggested aortic insufficiency, which an echocardiogram confirmed.  I also found point tenderness in the spine of a febrile drug user with a paravertebral abscess, a new systolic murmur in a woman who ruptured her mitral valve, and countless telltale rashes in young adults with disseminated gonococcemia.  As an attending, I've diagnosed small cell lung cancer in a smoker with a hard cervical lymph node, pseudomonas bacteremia in a patient with ecthyma gangrenosum, and tension pneumothoraces in intubated patients with hyper-resonance to percussion and plummeting  blood pressures.

Competent exam skills are well within the scope of any physician who pays attention.  Expert mentorship helps, but real mastery emerges with study and repetition, when you perform hundreds of thorough exams, confirm your findings with colleagues, and return to the bedside when you realize you missed something- like a couple of weekends ago in the MICU when a cardiologist heard a pericardial friction rub that we'd overlooked on rounds, which sent everyone back to the bedside to listen together.

Though I'm often skeptical about exam findings as they're reported, I'm not nihilistic.  Key exam findings are accessible to anyone with faith that they matter.  We all have the capacity to perfect our skills, but only if we agree that the effort is worth our time.  I hope I've convinced you that it is.

Enjoy your Sunday everyone. It's Heide's birthday and we're on our way to NYC to the Whitney Museum and Momofuko Ssam Bar.

Mark 

Submitted by Mark David Siegel on October 15, 2017