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Requests for reprints should be addressed to Abraham Verghese, MD, Stanford University, Department of Medicine, 300 Pasteur Drive, S102, Stanford, CA 94305-5110.
Oversights in the physical examination are a type of medical error not easily studied by chart review. They may be a major contributor to missed or delayed diagnosis, unnecessary exposure to contrast and radiation, incorrect treatment, and other adverse consequences. Our purpose was to collect vignettes of physical examination oversights and to capture the diversity of their characteristics and consequences.
Methods
A cross-sectional study using an 11-question qualitative survey for physicians was distributed electronically, with data collected from February to June of 2011. The participants were all physicians responding to e-mail or social media invitations to complete the survey. There were no limitations on geography, specialty, or practice setting.
Results
Of the 208 reported vignettes that met inclusion criteria, the oversight was caused by a failure to perform the physical examination in 63%; 14% reported that the correct physical examination sign was elicited but misinterpreted, whereas 11% reported that the relevant sign was missed or not sought. Consequence of the physical examination inadequacy included missed or delayed diagnosis in 76% of cases, incorrect diagnosis in 27%, unnecessary treatment in 18%, no or delayed treatment in 42%, unnecessary diagnostic cost in 25%, unnecessary exposure to radiation or contrast in 17%, and complications caused by treatments in 4%. The mode of the number of physicians missing the finding was 2, but many oversights were missed by many physicians. Most oversights took up to 5 days to identify, but 66 took longer. Special attention and skill in examining the skin and its appendages, as well as the abdomen, groin, and genitourinary area could reduce the reported oversights by half.
Conclusions
Physical examination inadequacies are a preventable source of medical error, and adverse events are caused mostly by failure to perform the relevant examination.
medical errors cause nearly 100,000 deaths per year. The causes are systemic problems of inadequate organization, a culture of nondisclosure, and cognitive diagnostic errors.
A potentially important type of error that has been given meager attention is deficiencies in physical examination.
The high-tech transformation of medical care has resulted in diminishing direct patient-physician interaction. Hospitalists in America might spend only 18% of their on-duty time in direct patient care,
and duty-hour restrictions have resulted in Internal Medicine interns spending on average only 12% of their time with patients but 40% of their time on computer-related tasks.
Diminished focus on the physical examination may result in important errors. We asked physicians to contribute clinical vignettes of oversights and errors in physical examination and adverse consequences that resulted from them. This database was created to identify the diverse types and characteristics of errors that can be made relating to the physical examination.
Methods
We designed an 11-question, qualitative survey for physicians, who were asked to send us vignettes of known instances of oversights in physical examination and to answer related multiple choice questions. The study was approved by the Stanford University Institutional Review Board; the detailed instructions to the respondent and the questionnaire can be found online at www.surveymonkey.com/s/8S6DL7V.
A link to the questionnaire was sent to approximately 5000 physicians of diverse specialties using a commercial medical e-mail marketing service (MMS Inc, Woodale, Ill), with an estimated 2800 of these having teaching affiliations. In addition, we used social media sites to disseminate the link, and we encouraged physicians to share the link. There were no limitations regarding type of specialty and clinical practice setting.
Data were gathered from February to June of 2011. Each entry was reviewed by 2 physicians. We excluded: entries that did not form a vignette (eg, “residents don't do rectal exams often enough”); entries missing critical information to form a vignette (eg, a failure to state what precisely was omitted/misinterpreted); entries with 2 or more vignettes combined when it became impossible to parse out which one was being addressed in the multiple choice questions. We corrected a response only when the answer to a multiple choice question clearly contradicted the vignette, suggesting the respondent selected the wrong box (eg, the narrative describes a missed hernia in a patient with pain because the abdominal examination was not done, but the respondent ticks “finding elicited but misinterpreted” in lieu of “failure to do relevant exam”).
Results
Of the 263 responses received, 55 were excluded; of the 208 remaining responses, 27 were corrected by the criteria described in Methods.
Sixty-three percent of vignettes reported that the oversight was caused by a failure to perform the physical examination; 14% reported that the correct physical examination sign was elicited but misinterpreted. Eleven percent reported that the relevant sign was missed or not sought, and 12% reported “other” as the cause of the deficiency.
Consequence of the physical examination inadequacy included missed or delayed diagnosis in 76% of cases, incorrect diagnosis in 27%, unnecessary treatment in 18%, no or delayed treatment in 42%, unnecessary diagnostic cost in 25%, unnecessary exposure to radiation or contrast in 17%, and complications caused by treatments in 4%.
The person thought responsible for the oversight was most often an intern or resident (reported in 95 of 208 cases or 46%), a primary care physician (84, 40%), a specialist (79, 40%) or fellow (18, 9%). Though there was no multiple choice option available to implicate one's self as the person responsible, 9 responders (4%) indicated themselves as the physician responsible.
The number of physicians thought to have missed an important aspect of the examination is shown in Figure 1. The oversight was typically discovered within 5 days (Figure 2). When participants were asked to estimate what percentage of practicing physicians have made a similar error to the one described, they estimated it to be >95% in 43 instances (20%), 50-95% in 42 instances (20%), and 5-50% in 78 oversights (37.5%), and less than 5% in 28 instances (28%).
Figure 1Distribution of number of overlookers for 208 oversights in physical exam.
The list of findings overlooked is long and diverse, but those that were missed more than 5 times included abdominal mass/organomegaly (n = 21, including 3 pregnancies and 2 distended bladders), diagnostic skin finding (n = 15, such as café au lait spots, neurfibroma, erythema migrans, syphilitic lesions, and meningococcemia lesions but not including herpes zoster), neurologic findings (n = 18), murmurs/rubs (n = 13, including 4 missed aortic stenosis, 3 missed pericardial rubs), lymphadenopathy (n = 10), groin hernia (n = 10) or scrotal/testicular pathology (n = 6), signs of peritonitis (n = 10), breast masses (n = 9), fracture or orthopedic finding (n = 9), congestive heart failure (n = 8), absent or abnormal pulses (n = 6), wound or ulcer (n = 6), bruising (n = 6), and herpes zoster (n = 5).
Forty-seven oversights involved the skin and its appendages including the breast, 37 were related to the abdominal examination, 37 involved the cardiovascular system, and 36 involved the groin/genital/rectal area. Supplementary Table 1 (available online) lists all items that were missed.
Discussion
Recent publications describe the decline of physical examination skills.
Our study highlights the consequences and suggests that many adverse events are preventable. Our survey suggests that the major cause for error is simply that the examination is not performed.
In addition to diagnostic consequences, approximately half of the vignettes report treatment consequences. Most oversights pertained to a limited number of overlookers, suggesting that some errors may be remedied if several people examine the patient. Although the majority of the errors were corrected within 5 days, even a delay of 1 hour might affect patient outcomes.
Examining a patient presenting with a complaint (as opposed to the “routine physical”) is a low-cost procedure that, when done with skill, can avoid the majority of oversights listed. Many diseases involving the skin or the nervous system cannot easily be diagnosed except by the examination, and for others the appropriate diagnostic test is indicated by the examination. The drop-down boxes of the electronic medical record deceptively suggest every patient has been thoroughly examined (and therefore can be billed), but it will be the responsibility of educators and professional organizations to make sure the electronic medical record truthfully reflects what was done.
A short checklist is suggested by our study: physicians should seek full exposure of the patient; there must be a mandate to examine hernial orifices and the genital and rectal areas in acutely ill patients or with pain. Pain should prompt a search for the lesions of shingles. Non-neurologists need a sound neurologic skill set because imaging does not show the functional deficits resulting from a lesion seen. For diseases like Wernicke's encephalopathy or Bell's palsy, imaging may not be diagnostic. Finally, there should be a greater emphasis on actually performing the examination. In short, physicians in training must be taught and evaluated at the bedside to diminish this kind of error.
Our survey was not designed to determine prevalence but to generate an anthology of physical examination oversights along with their characteristics. The vignettes are subject to recall and response biases. We set no time limitation on reports and did not ask responders to specify where they practiced medicine. Finally, even though we contacted thousands of physicians, only a small minority contributed vignettes, suggesting a cultural reluctance to admit and share errors, unlike for example in the aviation industry. We as physicians might work in an “ignorance trap” in which our physical examination oversights are rarely reported back to us.
Diligence in actually teaching and performing the physical examination and continuing efforts to improve bedside skills would diminish one kind of medical error and its consequences for the patient.
Acknowledgment
The authors thank Ralph Horwitz, MD, for his encouragement of the First Stanford Symposium on Bedside Medicine in 2009, and for his helpful discussions in planning this study.
Supplementary Data
Supplementary Table 1Complete List of Items Missed as Reported in Returned Questionnaires
Missed skin finding of subcutaneous emphysema
Missed pulse absence in ischemic foot
Missed pregnancy with twins before hysterectomy
Missed hip fracture labeled as right lower quadrant pain
Missed Bell's palsy
Missed liver mass, abdominal mass in cholangiocarcinoma
Missed funduscopic finding of cupping
Missed strangulated groin hernia in small bowel obstruction
Missed incarcerated femoral hernia
Missed crackles in a patient with pulmonary edema
Missed finger pressure necrosis on microvascular free flap
Missed peritoneal signs and free air on plain film
Missed peritonitis in patient with gangrenous perforated gall bladder
Missed adenopathy and therefore chronic lymphocytic leukemia
Missed thyromegaly in patient with tachycardia
Missed strangulated hernia
Missed fungating breast mass
Missed pelvic examination and therefore missed tubo-ovarian abscess
Missed pregnancy by missed gynecologic examination in patient with seizures
Missed pyoderma gangrenosum in skin
Missed Fournier's gangrene in groin—no genital examination
Missed clonus and hyperreflexia
Missed abdominal examination finding of tenderness and Grey Turner signs
Missed neurofibroma and café au lait spots
Missed large abdominal mass
Missed heart failure signs of cardiomyopathy after flu in a young person
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