We can be knowledgeable with other men’s knowledge, but we cannot be wise with other men’s wisdom.

Michel de Montaigne (1533–1592)

“Alas poor Yorick, I knew him, Horatio.”1 At the site of his wife Ophelia’s burial, Hamlet finds the skull of his lifelong friend Yorick. Yorick was Hamlet’s enduring constant companion. A monologue extolling their past relationship follows. And now, poor Yorick is gone forever.

The history and physical (H&P) is intended to be part of the fabric of a physician’s life, our lingua franca. Its mastery is the raison d’être of the second-year medical student. It is the price of admission to the electronic medical record (EMR). However, like a rock in a river, time has eroded the current rendering of the H&P. To wit: “The patient presents with a CT showing….” Alas, it has met Yorick’s fate.

The modern H&P can trace its origin from Hippocrates.2 Along its journey, we meet the many pivotal people and discoveries that changed the contemporaneous trajectory of medicine. The invention of the thermometer, reflex hammer, and stethoscope redefined diagnostic capabilities in their day, foretelling a new paradigm of medicine. With each new tool, the documented physical examination changed. The osmotic drag affected the questions we asked of the patient.

William Osler, while serving as chief at Johns Hopkins, emphasized bedside teaching (Fig. 1). Historically, medicine was taught in lecture halls. His maxim: “Listen to your patient, he is telling you the diagnosis.” He created the in-house residency, with residents living a monastic existence in the hospital. These were open-ended affairs, and graduation would be entirely discretionary. Osler stressed the significance of a thorough H&P of all patients. Those observations were immortalized on paper, giving birth to the H&P. Today’s “presentism,” where the past is viewed through modern sensibilities, criticizes Osler for his blatant and overt racism.3 Had Osler had his way, I would now have been euthanized (chloroform, mercifully), as he insisted that people over a certain age have no worth and should be killed.

FIGURE 1.:

William Osler, bedside. (Courtesy of the National Library of Medicine).

With exponential advances in laboratory testing and imaging, the utility of the H&P is now questioned.4 Why listen to the heart when an echocardiogram can give you more information? The CT images and MRIs endow us with Superman’s x-ray vision, so what use is the physical? I was trained to differentiate hypovolemic tachycardia vs septic tachycardia vs normovolemic tachycardia by taking a patient’s pulse. I dare say that no surgical resident actually feels a pulse, relying instead on the ubiquitous pulse oximeter.

Patients with acute undiagnosed disease will typically arrive through the emergency room. The blood tests and CT scans are de rigueur, and a diagnosis is suggested (“clinical correlation needed” to cover the radiologists). The surgical resident will diagnose an “appy” rather than an acute abdomen. Confirmation and anchoring bias now insinuate themselves into their surgical judgment. The surgeon anchors on the suggested diagnosis using H&P findings to confirm that suspicion.5 The question arises: Would a proper H&P before testing change anything?

Advocates of the importance of the H&P believe that the original patient interaction is critical for building trust. The resident meets the patient preoperatively so that the patient feels some continuity of care postoperatively. Some want to include their social determinants of health. Using poetic license, many surgical H&Ps include fictitious “complete physical examinations” documenting full oral, musculoskeletal, and neurological examinations.

The attending surgeon prepopulates the H&P in the EMR in the perioperative setting. The resident then reads about the patient they will operate on. All that information obviates the need to take a history or examine the patient preoperatively. The resident’s note is a cut-and-paste production, frequently completed before the patient’s arrival. At my insistence, the resident may begrudgingly take the history.

The office practice of colorectal surgery is not unaffected. Patients present with a diagnosis and imaging, engendering the same anchoring bias. When you get to the age where Dr Osler would have euthanized you, you see the patients whose surgeons were misled into the wrong treatment and diagnosis. These errors would have been obvious with a thorough history and careful review of imaging, which takes time.

In the not-so-distant past, serial physical examinations determined when to “drop the knife.” Those judgments now rely predominately on serial imaging. It is not uncommon for patients to receive multiple CT scans to aid in initial management or postoperative complications.6 Three abdominal and pelvic CT scans deliver 50 msv (millisevert) of radiation, the amount of radiation that the average Hiroshima survivor received. The higher incidence of cancer in these survivors is attributed to that radiation dose. The sequela of the liberal use of scanning may become apparent in the patient’s future.7

René Laennec invented modern auscultation in 1816. Previously, physicians performed direct auscultation by placing their ears directly on the patient’s body. Laennec had observed children at play using wooden tubes to transmit sound.8 Unable to hear the heart in a “fat woman,” in a Eureka moment, he took a sheet of paper and rolled it up to apply to the chest. It worked. He eventually settled on an 18-inch wooden 2-part tube. There were many physicians at the time who were expectedly against this method of diagnosis.9 Stethoscopes, once adorning the necks of the surgical house staff, seem to have gone out of fashion, replaced by the ID badge.

Surgery has always had a dynamic tension between innovators and nay-sayers. Those of us in Osler’s cemetery can remember the resistance to laparoscopy and, subsequently, to robotic surgery. The H&P may be at these crossroads again, resulting in a sea change in our practice. The H&P, in surgical specialties, will probably be used to confirm the diagnosis. The nuance of the complete history, uncovering symptoms perhaps not fitting into the preconceived diagnosis template, may be deemed inconsequential or be flagged by the EMR for more scrutiny, akin to the artificial intelligence (AI) toy nudging me during colonoscopy about the polyp I missed.

Modern medicine has tempered patients’ expectations. Today’s patients are getting accustomed to being reduced to aberrant biology. To maximize efficiency, the consultation room has merged with the examination room. The patient’s initial interaction with the physician is in an examination room naked except for a flimsy gown. This environment is not conducive to any in-depth history. Patients begrudgingly tolerate this as they do the “sorry for your inconvenience” that accompanies pretty much everything in our lives.

Understanding the pathophysiology of disease is predicated on knowing the patient’s thorough history. This will be lost. With the current emphasis on “outcomes,” this understanding of disease may be deemed irrelevant. Those who teach surgery may have a more difficult time relating any disease to a specific patient absent being cognizant of that patient’s H&P. We will revert to didactic teaching again. Osler would be rolling in his grave.

Colorectal surgery is truncated into abdominal and anorectal surgery. Clearly, the abdominal disease component of our lives will change. For many, endoscopies were traded away to gastroenterology in a Faustian bargain. Anorectal surgery, other than the overuse of CT and MRI, still requires a H&P examination. Happily, no machine is yet needed to diagnose an external thrombosed hemorrhoid.

Anorectal surgery will perhaps allow our specialty to hold off an impending Matrix-like tyranny. It requires empathy to deal with embarrassing anorectal disease. This may yet preserve some of the humanity of the doctor–patient interaction.

Voice recordings of patient encounters are now transcribed via AI into the EMR.10 AI can review records from other institutions. The patient’s social media information will be added.11 The patient’s genetic profile will be scoured for aberrant DNA.12 Abdominal imaging, exponentially improving, will further define the disease and its progression with far greater accuracy than a physical examination.13 AI will be needed to distill the overwhelming amount of data and suggest diagnosis and treatment. Just as the spell checker enables my sloppiness, the diagnostic and treatment suggestions made by such platforms may both intimidate us and make us lazy. AI, having devoured all of PubMed, is surely smarter than we mere mortals. Physicians may be anchored into a diagnosis without independently assessing the massive amount of data available.

I have watched every episode of 50 years of Star Trek (899 episodes, if you are interested), which takes place circa 2069 to 2382, and I can attest the ship’s physician never performed a H&P. As soon as one arrives in sickbay, a tricorder is waved over the patient, promptly rendering the diagnosis after the obligatory flashing lights (Fig. 2). Today seems like an embryo of that future.

FIGURE 2.:

Dr. Leonard “Bones” McCoy using a tricorder. (Courtesy CBS “fair use”).

Like Yorick, I knew him. The H&P will be replaced by things we can only imagine that will be totally alien to anyone reading this missive. It may be time, sadly, to leave him buried and embrace the new possibilities that await us.

The secret of change is to focus all of your energy not on fighting the old, but on building the new.

Socrates (470–399 bc)

1. Shakespeare W. Hamlet, Prince of Denmark. Mowat B, Werstine P, eds. https://www.folgerdigitaltexts.org/html/Ham.html#line-1.3.0 Published 2016. (Original work published 1599). Accessed October 7, 2023. 2. Walker HK, Hall WD, Hurst JW eds. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Boston, MA: Butterworths; 1990. 3. Bryan CS. Sir William Osler, eugenics, racism, and the Komagata Maru incident. Proc (Bayl Univ Med Cent). 2020;34:194–198. 4. Schultz MA, Doty M. Why the history and physical examination still matter. JAAPA. 2016;29:41–45. 5. Armstrong BA, Dutescu IA, Tung A, et al. Cognitive biases in surgery: systematic review. Br J Surg. 2023;110:645–654. 6. Harvard Health Publishing. Radiation risk from medical imaging. https://www.health.harvard.edu/cancer/radiation-risk-from-medical-imaging. Accessed October 7, 2023. 7. SCI AM. How much do CT scans increase risk of cancer? https://www.scientificamerican.com/article/how-much-ct-scans-increase-risk-cancer. Accessed October 13, 2023. 8. Montinari MR, Minelli S. The first 200 years of cardiac auscultation and future perspectives. J Multidiscip Healthc. 2019;12:183–189. 9. Walker HK. The origins of the history and physical examination. In: Walker HK, Hall WD, Hurst JW, eds. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Boston: Butterworths; 1990. 10. Walker J. At startup that says its AI writes medical records, humans do a lot of the work. Wall Street Journal. https://www.wsj.com/articles/at-startup-that-says-its-ai-writes-medical-records-humans-do-a-lot-of-the-work-794be22e. Published July 23, 2023. Accessed October 8, 2023. 11. Abnousi F, Rumsfeld JS, Krumholz HM. Social determinants of health in the digital age: determining the source code for nurture. JAMA. 2019;321:247–248. 12. Le DH. Duc-Hau Le Machine learning-based approaches for disease gene prediction. Brief Funct Genomics. 2020;19:350–363. 13. Yeh BM. Look ahead: the future of abdominal imaging. RSNA News. https://www.rsna.org/news/look-ahead-the-future-of-abdominal-imaging. Published June 29, 2018. Accessed October 9, 2023.