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Should Psychiatrists Perform Physical Examinations?

Should Psychiatrists Perform Physical Examinations?

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“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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