Other Features: Teaching and Learning Moments
I like walking with my patients. Besides providing information on their physical condition, it builds a good patient–physician relationship; it allows me to evaluate their gait, their need for rehabilitation, their fall risk. But also, walking with my patients gets me closer to them, providing a human touch to the relationship. Walking with a patient does not require any special experience, technology, or instrument, and it should be part of every physical assessment.
Unfortunately, we live in an era in which imaging and laboratory testing have taken priority over a thorough history and physical exam. A renowned professor in cardiology once looked at the book that I was reading and told me, “Stop wasting your time; just do an MRI.” The book was one of my favorites: Localization in Clinical Neurology. He smiled; I didn’t smile back. I did not think it was funny. But it helped me understand why, during my internship, my residents were often intrigued when they saw me walk with a patient. Even though this aspect of the physical exam is simple and routine, I noticed that it was often overlooked, which would sometimes result in unfortunate events. Two interactions from my rotation in neurology consults illustrate my concerns:
A 45-year-old man was admitted for urinary tract infection. It was his third episode within three years. He had had dysuria for those three years and was being treated for benign prostatic hypertrophy. He also had a spastic walk that had never been addressed. Physical exam showed upper motor neuron disease in his lower extremities with a T10-level sensation. A spine MRI revealed a T8–T9 herniated disc compressing the spinal cord. After spine surgery, the patient’s symptoms, including his dysuria, resolved.
A 70-year-old woman with mild dementia was hospitalized for pneumonia. She was ambulatory upon admission. Her stay was complicated by hypertension that was aggressively treated. She remained in bed for the total length of stay. Upon discharge, she couldn’t walk. Investigation showed that she had had a subacute stroke during her stay.
A focused physical assessment is more efficient than a complete evaluation, particularly for chronic patients. However, omitting certain aspects of the physical exam can sometimes lead to serious consequences. True, time is lacking, and we are always in a rush, but that should not compromise our patients’ safety. Solid assessments and wise use of available resources—ones as simple as focused attention to physical assessments—are what make medicine an art. Walk with your patients. They will heal quicker.
Chafic Karam, MD
Dr. Karam is a neurology resident, Department of Neurology, Albert Einstein College of Medicine, Beth Israel Medical Center, New York, New York; (firstname.lastname@example.org).