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Should Psychiatrists Perform Physical Examinations?

Should Psychiatrists Perform Physical Examinations?

“Good psychiatry begins
with a responsible Doctor
undressing the patient
and carrying out a proper
physical examination.”
—Pediatrician and
psychoanalyst Donald
Winnicott (quoted
by Issroff1)

In one of his inimitable essays, Richard
Asher tells of a patient whose retinitis
pigmentosa was diagnosed by an ophthalmologist. The ophthalmologist's
report concluded that the findings
suggested the Laurence-Moon-Biedl
syndrome. Was there, the ophthalmologist
asked, any evidence of polydactyly? Asher comments bitingly that surely this
is specialization run amok--can an eye
doctor not count the patient's fingers?

Asher—among whose accomplishments
were the description and naming of Munchausen syndrome—was an
internist who specialized in psychological
medicine. Behind his complaint
was the assumption that we are all
physicians first, specialists only afterward:
“A good doctor should be a jack-of-all-trades and master of one.”2 The
evaluation of the mental patient, from
his perspective, was first the job of a
physician. Should a physical examination
be part of that job description?

Psychiatrists specialize in mental
phenomena, but this special expertise
does not confer license to ignore the additional
information that can be gathered
from physical signs. For example, delirium
is well characterized in its psychological
dimensions by psychiatric
diagnostic manuals3 and commonly used
rating scales.4,5 Unmentioned in these
references is the near-pathognomonic
status of asterixis in identifying a toxicmetabolic
encephalopathy. Why would
one think that as a psychiatrist one has
no need of the techniques that are useful,
indeed necessary, for other specialists—or perhaps the question is, why would
one attempt to make a diagnosis with
one hand tied behind one's back?

Psychiatric patients commonly suffer
from general medical conditions;
often these conditions affect or even
produce the mental disorder.6 In formulating
the psychopathologic condition
and identifying its cause, why would
one want to forgo tools that generations
of physicians have found useful
in the diagnostic endeavor?

For several decades, commentators
have pointed out that psychiatrists
endorse physical examinations more
often than they perform them.7 Those
who omit performing a physical examination
offer several reasons. Concern
about the psychological impact of the
physical contact or intrusion is prominent.
Lack of appropriate facilities for
physical examination and lack of sufficient
skill are mentioned.

Of course, psychiatrists must be
concerned about the meaning of the physical examination to the patient.
Under certain circumstances, to refrain
from performing a physical examination
may be wise. For example, imagine
a patient referred by a trusted
oncologist colleague. The patient, with
a recent diagnosis of cancer, has been
through the mill of consultations, examinations,
and invasive investigations.
The referral letter from the oncologist
indicates the lack of cerebral disease in
the staging evaluation. The patient's
mental state gives no hint of an organic
mental disorder; rather, the patient
seems to be worn out by the process of
becoming a cancer patient and to want
to talk with someone about it. Such a
person might do best to talk with a
psychotherapist, who is not doing any
physical poking and prodding. At least
this judgment is one a reasonable clinician
might make.

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