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The Coordinator's Column: Too much of a good thing?
Posted on: 12/5/2016
Brian S. Zachariah, MD
Chief Medical Coordinator Division of Professional Regulation, IDFPR

Most of us learned in medical school the importance of the history and physical exam (“H&P”). Depending on where you trained and who was speaking, you probably learned that the H&P led to 80, 85, even 90 percent of diagnoses. Given the primacy of the H&P in patient care, is there ever such a thing as a “too–thorough” history and physical? Based on the frequency of complaints received by the Department alleging unprofessional conduct, unnecessary exams and even sexual misconduct associated with exams, the answer seems to be “yes.”

While patients sometimes object to (and complain about) what they perceive as inappropriate or intrusive history questions (for example, those concerning drug use or sexual history), these concerns can usually be allayed or prevented by a clear explanation of their importance and role in the therapeutic encounter. More common, and more complex, are the complaints involving the physical exam.

The usual scenario encountered by the Department involves a female patient referred by her primary care physician to a male specialist for evaluation of what the patient perceives as an isolated complaint, such as chronic abdominal pain. As part of the evaluation of this complaint, the specialist conducts a sensitive exam, for example, a pelvic exam or breast exam. This sensitive exam is then viewed by the patient as unnecessary, unprofessional, or even sexual misconduct, leading to a complaint being filed against the specialist.

As part of the ensuing investigation, the respondent physician usually provides one or more of the following explanations: 1) the exam was part of the evaluation to address the patient's complaint; 2) while a specialist, the physician is also first and foremost an internist and performs a head-to-toe full and complete physical examination on all new patients; and 3) the patient presented with a complex problem; therefore, a "comprehensive" exam was performed (including the sensitive exam of concern to the patient) in order to document the encounter in a way that ensures proper reimbursement.

This last rationale is problematic in that the level of exam indicated and performed should drive the bill submitted, not the other way around. Complicated billing and coding discussions typically fall outside the purview of the Department and are beyond the scope of this column. However, one can easily imagine how this explanation is perceived by patients.

The second explanation may well be reassuring to many patients, provided certain caveats are met. First, the patient should understand that this is the physician's usual practice and why this is so. Second, the patient should have a clear opportunity to opt out of any or all individual components of this head-to-toe examination – for example, if she recently had a pelvic or breast exam by her primary care physician or OB/GYN. Most importantly, regardless of the circumstances, the exam must be conducted in a professional manner with full informed consent.

Even in circumstances where the sensitive exam was clearly medically indicated, or the physician would be potentially negligent to omit it, (for example, a testicular exam in a man with chronic abdominal pain), patients often complain because they were never informed why this particular part of the exam was being performed. They also complain because they were exposed rather than appropriately gowned or draped during the exam. In a similar vein, patients often complain because no chaperone was present during the sensitive portions of the physical exam.

After investigation, most of these complaints are closed without any discipline levied against the physician's license. However, as is always the case, the Department would rather prevent than respond to these allegations. I trust that all practicing physicians feel likewise. A few simple guidelines should help meet this goal. The caveats above are a good start. In addition, a comprehensive and proactive chaperone policy should be in place for most offices where sensitive exams are performed. Finally, one should carefully explain how and why exams will be conducted, and special attention should be paid to the patient's modesty and dignity when performing these exams.

Brian S. Zachariah, MD, is a contributor to Physician Advocate. He is the current Chief Medical Coordinator, Division of Professional Regulation, at the Illinois Department of Professional and Financial Regulation.

Disclaimer: Views and opinions expressed in the "Coordinator’s Column" are those of its author and are not necessarily endorsed by ISMS. This column does not necessarily reflect official policy of ISMS, but is intended to raise issues of importance to its members. Comments and questions regarding the content of this column may be directed to the author at brian.zachariah@illinois.gov.

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