“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.
1. Issroff J. Winnicott and Bowlby: personal reminiscences. In: Issroff J, ed. Winnicott and Bowlby: Personal and Professional Perspectives. London: H. Karnac Books; 2005:13-69.
2. Asher R. The seven sins of medicine . In: Avery Jones F, ed. Richard Asher Talking Sense. London: Pitman Books; 1972:70-76.
3. American Psychiatric Association Task Force on DSM-IV. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. Washington, DC: American Psychiatric Association; 1994.
4. Gonzalez M, de Pablo J, Fuente E, et al. Instrument for detection of delirium in general hospitals: adaptation of the confusion assessment method. Psychosomatics. 2004;45:426-431.
5. Trzepacz PT, Mittal D, Torres R, et al. Validation of the Delirium Rating Scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium. J Neuropsychiatry Clin Neurosci. 2001;13:229-242.
6. Yates BL, Koran LM. Epidemiology and recognition of neuropsychiatric disorders in mental health settings. In: Osview F, ed. Neuropsychiatry and Mental Health Services. Washington, DC: American Psychiatric Press; 1999:23-46.
7. McIntyre JS, Romano J. Is there a stethoscope in the house (and is it used)? Arch Gen Psychiatry. 1977;34:1147-1151.
8. Tasman A, Kay J, Lieberman JA. Psychiatry. Philadelphia: WB Saunders; 1997:540.
9. Sanders RD, Keshavan MS. Physical and neurologic examinations in neuropsychiatry. Semin Clin Neuropsychiatry. 2002;7:18-29.
10. Garden G. Physical examination in psychiatric practice. Adv Psychiatr Treat. 2005;11:142-149.
11. Ovsiew F. Neuropsychiatric physical diagnosis in context. In: Yudofsky SC, Kim HF, eds. Neuropsychiatric Assessment. Washington, DC: American Psychiatric Publishing; 2004:1-38.
12. Jones DR, Macias C, Barreira PJ, et al. Prevalence, severity, and co-occurrence of chronic physical health problems of persons with serious mental illness. Psychiatr Serv. 2004;55:1250-1257.
13. American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity. Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care. 2004;27:596-601.
14. Marder SR, Essock SM, Miller AL, et al. Physical health monitoring of patients with schizophrenia. Am J Psychiatry. 2004;161:1334-1349.
15. Reisin E, Alpert MA. Definition of the metabolic syndrome: current proposals and controversies. Am J Med Sci. 2005;330:269-272.