RESPECT, EMPATHY AND SINCERITY IN THE PHYSICAL EXAMINATION - the Seven Habits of Professionalism in Physical Examination Dr. T.

Thirumoorthy The physical examination is an essential element in not only collecting information for diagnosis, but another important step in building of the doctor patient relationship. Patients expect the doctor to be thorough, systematic and gentle in carrying out the physical examination. To apply the principles of Respect for persons in medical practice as embodied in the concern for the patients welfare and respect for the patients wishes, an expected professional behaviour is exhibited during the physical examination. The 7 important domains in physical examination should form part of professional habits embedded into the daily routine of patient encounters. 1. Introduction, Intention and Consent The clinician is to introduce himself and the role in the medical care team Explain clearly what is the intention, the reasons and what the patient can expect to encounter Get consent and assent before starting 2. Ensure Privacy and Preserve Modesty Curtains and screens drawn out with doors locked All female patients should have a chaperone unless objected by the patient. Patients should be adequately draped. Expose only the area needed for examination Allow time to undress and time to put on the clothes 3. Well rehearsed physical examination techniques Have clear understanding of the examination techniques and what is to be elicited by comprehensive cover of the book materials. Sufficient practice of the technique on self, fellow colleague, manikins or Standardized patients Sequence of examination should be least disturbing to the patient. Minimise the number of times the patient has to change positions. Be prepared to spend more time in doing a physical examination on the elderly, the handicapped or on children. Examination must be comprehensive and accurate. 4. Sensitive to pain and discomfort Warm and clean hands. Start with gentle superficial palpation before deep palpation Observe the patients body language for any grimacing or signs of pain Adequately warn the patient on any potential discomfort Stop at once if pain is elicited.

5. Effective Communication Inform the patient at each step of the examination. Inform the patient of change examination from one area of the body to another. Give clear instructions to the patient when you expect him to do a maneuver as is commonly done in the examination of the nervous system. Avoid inappropriate conversations, comments or facial expressions. 6. Avoid interruptions Avoid any distractions or interruptions like answering phone calls Do not leave the room in the middle of the examination. 7. Appropriate closure Inform the patient when the examination is over Ask the patient if he has any special concern of any area of the physical examination, that needs special attention Ask the patient if he has any questions Do not discuss the findings of the physical examination, until the patient is fully dressed Explain the next step in the consultation

A systematic and accurate physical examination would yield important information to arrive at the diagnosis and help timely relieve of his disease. Missing out an area of examination for concerns of embarrassment or inconvenience may cost the life of the patient. A timely detection of a breast lump or tumor in the rectum or scrotum can be life saving. A thorough examination can be carried out gently and proficiently with good practice and observation of the good professional behaviour. A well done physical examination gives an impression of caring and competence to the patient, which is bound to build trust and the relationship.

Prepared for Practice Course Year 1 by Dr T. Thirumoorthy Associate Professor, Duke-NUS Graduate Medical School, Singapore Sept 2009