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The Doctor Files

When Hang-Ups Hinder Physicals

April 23, 2001|Claire Panosian Dunavan

No one loves a physical exam. Talking to the doctor is one thing, being ogled and probed is something else, right?

Patients aren't alone. Doctors also have mixed feelings about physical exams. The reasons? Too little time, of course. Also, with so many diagnostic tests these days, basic physicals sometimes take a back seat. Finally, there's the issue of reticence. Many doctors who wouldn't hesitate to crack open a chest (under anesthesia, of course) still have qualms about probing a patient's private parts.

It was fall 1973 when I first noted my own natural reticence and my peers' regarding bodily examination. That's when we second-year medical students donned fresh white coats, packed our doctor bags and marched two by two into hospital rooms. The brave patients inside had actually volunteered for "Physical Diagnosis," our basic training in the laying on of hands.

Jim and John were brilliant classmates who had aced first-year courses like anatomy and biochemistry. Jim, in particular, was a wizard at memorizing. Now he was chapters ahead in the intricacies of "P-Dog," medical school shorthand for physical diagnosis. I, on the other hand, was still learning to use a blood pressure cuff and adjust my stethoscope on the first day we would handle patients.

Fortunately, my partner and I were assigned to a kind leukemia patient who smiled after each of our sweaty, determined maneuvers. Finally reaching his abdomen and finding his enlarged spleen--a fleshy, malignant peninsula--was a shocking marvel.

Down the hall, Jim and John reported to the room of a near-deaf, elderly woman. Jim, according to later accounts, grew nervous the moment he entered. Then, before his fingers ever grazed skin, he started trembling. Desperate, he tried to excuse himself. But the patient didn't hear him. Finally, he yelled, "Dr. John will now take over the physical exam," and fled. To his chagrin, his P-Dog debut was soon the buzz of our class.

Like most medical students, we eventually mastered the mechanics of the physical exam. Today they're as natural as, say, driving a car. But when it comes to the intimate terrain of the human body, even old-timers can find themselves emotionally vulnerable. For example, some of my male doctor pals admit that they still blush when they have to examine a Playboy model look-alike. I once had to massage the prostate of a well-known actor. I too got rosy.

Other doctors are more enamored of the science of medicine than the human body. Given the choice, they would never touch a patient. Back in medical school, many of these classmates chose fields that steered clear of live examinations--psychiatry, radiology, pathology, administration. But some also became clinicians and may still, with mixed emotions, be pressing flesh today.

None of this would matter to patients unless, every once in a while, the difference between a thorough and a shoddy physical exam equaled life and death.

Take the case of "Ethel," the 83-year-old mother of a close friend. A widow with failing memory, Ethel now has daily in-home care. But she still sees doctors. In fact, medical appointments are among the most frequent entries in her calendar.

Last year, Ethel's longtime internist sent a letter terminating his relationship with her. The reasons weren't clear, but my friend didn't press the issue. Instead, she quickly found her mom another physician. On the first visit, the new internist performed a complete physical exam. Sure enough, he found a walnut-sized genital growth. Further evaluation showed cancerous spread throughout Ethel's abdomen and pelvis ultimately requiring surgery, radiation and chemotherapy.

How long Ethel's first doctor, who had previously seen her regularly, had cut corners with his quick "slip off your blouse and let me listen to your heart and lungs" exams is anyone's guess. But one thing is sure: His lapse now threatens her life.

Full physical exams are not indicated during every medical appointment, nor is every doctor expected to visit the body head-to-toe. But patients, parents, caregivers, be sure you and your loved ones aren't being shortchanged the basics. And don't discount your instincts if you think you are. Diabetic patients need regular examination of eyes and feet. Why? Because they are among the most vulnerable targets of the disease. Body scans and PSA blood tests are no substitute for simple rectal exams to detect early prostate cancer. Elderly women still need gynecologic exams. And frail people of any age who can't or won't voice complaints often merit the most painstaking exams of all.

In the best of worlds, the physical exam is a contract. At the exam room door, both doctor and patient should agree to let go of their hang-ups but hold tight to common sense and humanity.


Claire Panosian Dunavan is an infectious diseases specialist practicing at UCLA Medical Center. She can be reached at The Doctor Files runs the fourth Monday of every month.

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