And just like with the hand physical examination and a good old-fashioned handshake, I make sure to look at the patient’s eyes and examine the facial expressions, as well. Complex emotions, such as excitement, fear, anxiousness, distress and resentment, may show up in the face early in the appointment. These cues can guide history taking and physical examination, making them much more appropriate and nuanced.
The handshake is also a large part of how I avoid getting stuck to the computer screen. It’s no secret that clinicians interface with their computer screens significantly during outpatient encounters.8 Nobody can blame physicians for doing so, but there are downsides of such inattention to the patient. A simple handshake and a look in the eye can really prime the encounter so the whole time feels a little bit more patient centered.
Not Just Handshakes
The handshake is only one of the many elements of the physical examination that are often overlooked. Because observation is at the heart of the physical examination, and, according to many experts, is the most critical element of the physical examination, it is important for clinicians to be deeply immersed in our patient encounters for the purposes of the physical examination.9 The dermatologic examination (of exposed areas) and neurologic examination (for speech, symmetry and coordination, among others) are good examples of where deep inspection can happen seamlessly during a patient visit without much extra time added.
Much like how a handshake can initiate and prime the clinical encounter, accompaniment of the patient to the front desk can be a great way to end an encounter. By carefully observing a patient’s ability to get up from a seated position and inspecting their gait, a clinician can get a holistic understanding of the sense of their musculoskeletal function. At the same time, by literally joining with the patient throughout the encounter, clinicians can demonstrate a commitment to their well-being without adding much time to the encounter.
In fact, while we tend to split history taking and the physical examination into binary opposites—one that we solicit and the other that we elicit—a comprehensive physical examination unites the mind and the body. The physical exam, when conducted properly, can complement what is stated in the history and vice versa. When documented accurately, the physical exam can also be a vivid and unique reminder of the patient’s burden of disease and manifestations of illness.
