A future without history and physical exams

In the 1960s the Star Trek television series took the viewer to life on a spaceship traveling beyond our solar system. Dr Leonard “Bones” McCoy, medical officer of the spaceship, was equipped with a tricorder, a medical device that could scan a patient, read their vital signs, and diagnose problems in minutes.

Today, here on Earth, we still don’t have tricorders, but advances in artificial intelligence, computer technology, and other information-processing sensors and scanners and diagnostic equipment make it possible to interpret and integrate data from an array of sources. These developments have the potential to reduce diagnostic and prognostic speculation and enhance a more personalized answer to our patients’ presenting problems. It looks as if the time-honored history taking and physical exam may head toward major changes, perhaps atrophy if not obsolescence.

As children, my friends and I used to play “guess my profession.” I loved to mimic a doctor’s use of a stethoscope or knee hammer, which I thought were hallmarks of a doctor’s work. Years later, in the early 1950s, I reached my dream; I was in medical school at UBC. To my delight there was a great emphasis on history and physical exams, and I practised the percussion technique for hours, trying to hear the nuances of heart murmurs.

The history of medical practice is characterized by ongoing changes—some slow, some fast. In my student days the history and physical imperative of our revered Professor of Medicine was essentially still an elaboration of Dr William Osler’s model from the late 1890s. Osler’s approach evolved by a synthesis of some 3000 years of medical experiences. Hippocrates was the first to propose a rational basis to illness, although it took 1500 more years before Vesalius accurately pictured human anatomy. Another 160 years later Sydenham defined disease states, which led Morgagni in the late 1700s to lay the foundations to pathology as a discipline. Also in the late 1700s physical diagnosis of ailments began with the introduction of percussion of body cavities by Auenbrugger. Laennec invented the stethoscope in 1818, introducing a technology to the art of auscultation, although it took some 30 years for that new technique to catch on. Physical diagnosis at the bedside and in the autopsy room gained secure footing in German and French schools in the late 1800s, and then Osler synthetized and applied the accumulated knowledge at John Hopkins University. He revolutionized both medical education and the practice of medicine.

A thorough history and an in-depth physical exam, supplanted by a few laboratory tests, are still the hallmarks of good medical practice. But the future is coming. At the first appointment a technician standing by a spectacular machine may print out intricate lists of the patient’s overt and covert biological status. Minimal physical exam might be needed. Then the doctor may receive a lengthy machine-produced list of alternative treatment methods. Now the demand on the doctor would shift to obtaining an in-depth personal history, first to analyze and then to recommend the best-fitting therapeutic intervention, possibly to be carried out by a another machine. In that scenario, the future physician’s role will be less as a diagnostician and more as a healer. Not a bad alternative. But what will future children mimic in their game of “guess my profession”?
—George Szasz, CM, MD

Suggested reading
Rutecki GW. Is the history and physical examination worth performing anymore? Accessed 10 October 2019. www.kevinmd.com/blog/2013/02/history-physical-examination-worth-performi....

Walker HK, Hall WD, Hurst JW, editors. Clinical methods: The history, physical, and laboratory examinations. 3rd edition. Burlington, MA: Butterworths; 1990.

Warmflash DM. Are the history and physical coming to an end? Medscape. Accessed 10 October 2019. www.medscape.com/viewarticle/917730.

This blog post has not been peer reviewed by the BCMJ Editorial Board.

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