BENEFITS FOR GPS AND PATIENTS
As GPs we are rightly proud of our focused history-taking and consultation skills, but how many of us would say the same for our focused examination skills? It is time to claim the focused clinical examination as a specialist GP skill we can be proud of, for us and for our patients. GPs will benefit as we start to understand what is really worth doing and what isn’t, in the GP setting. We will begin to feel more confident in what we do (and what we don’t do) in practice; perhaps we can even start teaching and assessing the focused exam properly, something too often glossed over in GP training. Patients will win because appropriate examinations can cut errors and avoid diagnostic delays,1 reduce unnecessary and potentially harmful tests,2 and provide a reassuring connection with their doctor.3 A well-targeted physical examination can double the diagnostic value of the history alone,4 and, as well as being a vital hypothesis tester, can be a crucial hypothesis generator in primary care.
BEAUTY IN SIMPLICITY
The GP examination is like the work of Picasso. Picasso first achieved complete mastery of complex techniques before creating works of divine simplicity. Similarly, our GP examinations are grounded in the comprehensive drills that we learned at medical school but which are then subject to expert focus, guided by the questions we are asking or the hypothesis we are testing. It is a skill that we hone and refine with experience, and one in which we should take great pride. And, yet, do we sometimes feel a little shame that we aren’t always performing a full PACES-style examination? Is there a mini-devil on our shoulder scolding us for ‘cutting corners’? Do we embellish our usual respiratory examination just because our patient is a chest physician, carefully checking for clubbing? We should not. It is only once we really value the beautiful simplicity of general practice examination that we can make it the best it can be.
MORE EVIDENCE NEEDED
We need more research and evidence about the focused GP examination. First, we need passionate researchers to capture what GPs are really doing when we examine patients — maybe like pioneers Byrne and Long, who spent three and a half years in the 1970s observing GP consultations to find out how we were talking with patients.5 Their work transformed our understanding of the consultation and formed the foundation for most of the models we have come to know so well. We need qualitative research to discover what is special about our focused examination skills, including how and when we choose to use which ones. We could also do with evidence-based guidance on the diagnostic value of different examination signs; JAMA has published some impressive work on the rational clinical examination6 — could we do something similar but tailored to UK general practice? A few questions that spring to mind:
what is the real value of a rectal examination when we’re referring a patient via the 2-week cancer pathway anyway (who needs two fingers up their bottom when one will do?);
what is the most efficient way to examine a painful knee to inform our management; and
are there any more clinical prediction rules like the Centor criteria for sore throats or the Ottawa ankle rules that could help us make more evidence-based decisions?
TEACHING AND LEARNING
There is a real hunger among trainers and trainees to learn how to do better GP examinations. They watch countless Youtube videos, often as long as the entire GP consultation, and mostly purely technical with minimal reference to the ‘why’. We need tools that not only reinforce the technical skills but also the critical skills that guide and focus the examination for the patient in front of us. We need to train trainers to be more confident at teaching examinations, and we need to reflect as experienced GPs on how we can develop our examination skills throughout our career.
With real commitment to the cause, we can make our focused examinations the best they can be. We can use this as a platform for training and assessment, for the benefit of our patients. At a time of low morale in the profession we should take pride in our generalist’s focused physical examination; it has the potential to be a sophisticated specialist skill worthy of celebration.
- © British Journal of General Practice 2017