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Whatever Happened to Physical Exams?

Dear Dr. Roach: Why has the physical exam all but disappeared from a doctor’s visit? When I go to a doctor, I am lucky to have my lungs and heart listened to with a stethoscope. I cannot remember when a physician has felt my abdomen, listened to my chest, felt my lymph nodes, felt for pulses in my arms and legs, looked in my ears, looked in my eyes, etc. I have MS and also a strong family history of vascular disease. I visit the doctor every six months. Rarely does he or she touch me. As long as my labs are OK, I am sent on my way.

This phenomenon is not limited to one doctor. I am a retired RN who has watched hundreds of doctors examine a patient in the hospital. Is the physical exam not taught in medical school anymore? — R.J.

Answer: The physical exam is still taught in medical school. I don’t want to offer any excuses for not doing a physical exam, as I think a physical exam is an essential part of a doctor’s visit.

I think the reason it isn’t done is time pressure. A typical doctor’s visit now is 14 to 18 minutes long, and hospitals and managed-care organizations have requirements that take up much of that time. When pressed for time, doctors search for ways to make diagnoses and manage conditions that are efficient. Talking to patients is the most efficient way of finding out what is wrong, although I still think we doctors often don’t spend as much time doing that as we should. Ordering lab tests is quick, and is sometimes helpful, but it often isn’t diagnostic and the patient ends up without an answer but with a large bill. Taking a bit more time, listening, and doing an appropriate exam may actually get the answer faster and much more cheaply.

I wish I knew how to change the system.

Dear Dr. Roach: I have been diagnosed with hyperparathyroidism. I have not seen this discussed before. My doctor suggests surgery. Is there any other treatment, and what kind of surgeon is recommended? Can it be done in our small local hospital by a local surgeon? — P.W.

Answer: Hyperparathyroidism is most often caused by overactivity of one of the four parathyroid glands (so called because they sit around the thyroid gland in the neck). Parathyroid hormone is essential for calcium metabolism and for bone health. Symptoms of excess parathyroid hormone include kidney stones, abdominal pain and depression. In severe cases, bone pain and weakness can occur, but this is rare now, since most people are diagnosed because of high calcium levels found during routine blood testing.

Treatment can be accomplished with surgery or medications. Anyone with symptoms is a candidate for surgery. For people with no symptoms, those who are younger than 50, with very high calcium levels, loss of kidney function or severe bone loss probably should have surgery.

The surgery can damage one of the nerves to the vocal cords, even in the best hands. For that reason, I recommend getting the most experienced surgeon around.

Dear Dr. Roach: Can you suggest an herb or medication for treating tinnitus? —J.G.

Answer: Tinnitus is the sensation of sound when there isn’t any. For many people, it’s a high-pitched whine, but it may sound different to different people.

No medication or herb has been proven to be helpful for tinnitus. In my experience, sound therapy — the use of white noise — is an effective treatment. The American Tinnitus Association has a great website (www.ata.org) with information and support groups.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or write to P.O. Box 536475, Orlando, FL 32853-6475.