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The Lost Art of Thorough Assessment – The Value of a Good History and Physical Exam

Updated: Jan 16

Maybe ten to fifteen minutes with your provider? A couple of quick questions, poking around where you told them you have pain, two or three movements to constitute a physical exam. Onto the next one. Sound familiar? We hear this kind of experience frequently from people. In some cases, this may be sufficient, but we feel that in the vast majority of cases this doesn't cut it. Below, we'll discuss the importance of a good history and interview, as well as the importance of a good, thorough physical exam so that we can more confidently get you on the right path to recovery.


In the last few years, it seems like we're losing a grip on the "care" part of healthcare. There are a number of factors driving some of the trends, but in the last several years, we have seen an incongruent increase in the number of administrators and executives relative to the number of healthcare providers. Concurrently, we've seen pressures greater than ever to see more people and to order more tests and perform more procedures, even if the research we have available doesn't support it. This has resulted in less time for you as a patient with your provider and often a greater expense to you. You might ask – what can we do about it?


As a healthcare consumer, there are a few points of advice. First, learn about your providers and their companies before seeing them. Often times, if you go to a larger system, they will encourage or even pressure you to see other providers within their system. But, what if their other providers aren't a good fit for you? What if the other providers' offices aren't convenient for you? Get to know how they can help you before jumping into the wheel. Second, ask how they operate. If you need to see a physical therapist, but an office is going to give you a 30-minute exam with a physical therapist and the rest of your time will be overseen by an unlicensed provider until you either get better or don't, then your needs aren't being met. If you have several questions pertaining to your health, but your physician can only see you for 8-10 minutes, is this going to meet your needs and help to keep you healthy? All of this leads to the focus of our post – getting back to a place in healthcare where you can expect your provider to spend quality time with you and for your provider to thoroughly investigate what may be going on.


Up ahead – The elements of a good healthcare provider


The importance of a good history and interview

A case example of why a good physical exam matters

Thorough doesn't have to mean "high-tech" or "complex"


 

A Thorough History Tells Us a Lot

We know pretty well at this point that pain in a location doesn't just mean that the cause is in that area. It could be, but it is doing you a disservice to assume so. This is why a thorough interview and history is necessary to make sure you get the care you need.


You don't have to take our word for it. Google "Cloward sign" for a well documented instance where pain in one region is referred from another (here, pain that seems inside and/or just between the ribcage and shoulder blade is being referred from the neck). We see this routinely – buttock and hip pain can come from the lumbar spine or hip joint; shoulder-area pain can come from the neck, rotator cuff, shoulder joint, etc. So why does a good interview matter?


Below in our discussion of a good old-fashioned physical exam we'll make mention of some relevant interview points as well, but as simple as it seems, targeted questions can tell us a lot. If you tell me you have pain in the buttock/hip area, knowing that structures from the lumbar spine (i.e., low back) can generate symptoms like this, it is important to try to explore scenarios that would perhaps tell us if symptoms seem secondary more to the hip joint-area structures v. the low back. If we don't take the time to ask a lot of structured, targeted questions and don't try to discern and differentiate potential causes of your pain, we're left to either perform a flawless and thorough physical exam lest we run the risk of making an assumption and potentially being wrong. Even the behavior of your symptoms can provide us with valuable information. We have several published studies available that show common patterns of how joint osteoarthritis, nerve-related causes of pain, etc. behave, but if we're not asking questions about how intense your symptoms can get, how long they last, how they behave in the morning v. throughout the day v. nighttime, etc. then we are missing a lot of valuable and very relevant information. You might be amazed at how many times we've caught things like UTIs, kidney infections, and even cancer-related symptoms that presented like orthopedic issues – just because we asked the right questions.


A Good Physical Exam Goes a Long Way

Here we're going to share a personal story. A close family member of ours developed sudden and intense pain that radiated from the top of his shoulder blade and down the outside of his arm to his elbow. While this was more constant, he could have intermittent pain that radiated down the forearm to just above his wrist. His primary care physician in his hometown spoke with him for a few minutes, ordered a shoulder X-ray, and came back to say that he likely had a rotator cuff issue and that he needed to see an orthopedist. We spoke shortly after this encounter – unfortunately, in this few-minute encounter, not many questions were asked regarding his symptoms, and nothing was done in the way of a physical exam. Simply asking him to turn his head and neck in the direction of his painful arm immediately provoked his pain. Raising his arm had no effect on his pain.


It's not terribly common where things provide such a clear-cut contrast like this. More often than not, we'll see a situation like this where arm pain is slightly bothered by arm movements but also impacted by elements of the examination of the cervical spine (or neck). Nevertheless, if we omit portions of the physical exam due to our bias as providers, we likely are going to miss things (like the case of my family member). Things like reflex testing, sensation testing, and general strength testing can help identify nerve-related dysfunction. In the case of my family member, there were very clear differences in their biceps reflexes, another element that would point away from the issue just being a shoulder issue and more likely being related to the neck and nerve structures of the neck. Ultimately, a thorough interview will help us to know what we need to closely examine v. what we need to still at least do a screening exam to confirm these suspicions.




"High-tech" and "complex" aren't the same as thorough


Like with the case of the family member above, a shoulder X-ray didn't add value. Don't get us wrong – there are certainly some very well defined times where imaging is important. For many of these instances, we have pretty solid guidelines (e.g., Canadian C-spine rules, Ottawa foot and ankle rules, etc.) that help us know when there is a greater likelihood or risk of something significant that our clinical physical exam may not be able to detect. In the case of the family member, the history and physical exam actually would have warranted an X-ray, although not of the shoulder. More and more we see a tendency in healthcare for advanced imaging and the like to be done immediately. In a high percentage of cases, the data simply suggests that this will lead to greater costs incurred for you as a consumer without necessarily getting value out of it.


Ultimately, seeing a provider that's well versed in medical screening, that will take the time to go through a comprehensive interview/history and physical exam with you, and that will take the time to discuss the findings and appropriate next options is your best bet. Don't get us wrong – there is a time and place for things like imaging, blood testing, etc., but we run the risk of making mistakes and missing important things when we exchange them for simply spending the time with you in the office to ask the right questions and to examine the right things.



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