From Lewis S. Blevins, Jr. MD – The practice of medicine has undergone considerable change since I graduated from medical school in 1987. Some of the changes have been revolutionary in response to advances in our understanding of human physiology and the molecular basis of disease states. Technological advances have certainly enabled beneficial changes in our approach to diagnosing and evaluating responses to the management of diseases. Further, advances in pharmacology and drug development have created remarkable opportunities for treating a variety of diseases.
While the field of medicine has changed dramatically in so many ways, some things have remained the same. For example, the general approach to the patient, including the history and physical examination, along with the complexities of medical decision-making, represents the foundation of the practice of medicine and is very much the same as it has always been. This is likely because of how our minds assess situations, make inferences, and devise approaches to solve problems. Whether it’s truly understood, the “scientific method” seems innate. This process is modified, incorporating both the art and science of medicine, informed by biomedical research in the basic and clinical sciences, critical observations and thinking by astute clinicians, and the process of failure analysis through morbidity and mortality conferences.
Some of these traditional approaches to medicine are, in my experience, somewhat restrictive or misdirected and need to change. I’ll comment on two general aspects of the history and physical examination that I feel need to be overhauled or approached differently, as an example.
First, let’s consider the comprehensive history and physical examination.
There’s no doubt that it is important for those undergoing annual evaluations by their physicians to have a sense of a comprehensive investigation to detect disease states sooner rather than later. However, when evaluating patients for specific presenting problems, much of the complete history and physical examination can be a waste of time and may detract from other important considerations and investigations. I think of every question asked and every physical exam procedure as tools. I believe that tools should be employed when necessary. For example, if you’ve seen thyroid function tests that show that the gland is working entirely normally, there’s no point in asking patients about symptoms and signs that relate to hypo or hyperthyroidism. If you know a patient has a normal IGF-1 and growth hormone and does not appear to be acromegalic, there’s no point in asking about symptoms of acromegaly. If a patient has hyperthyroidism due to thyrotoxic Graves’ disease, I don’t see a point in doing an abdominal examination. I can think of a multitude of similar situations, but the point I want to make is that sometimes a comprehensive line of questioning and routine physical exam procedures are not required. It is important to teach medical students and resident physicians how to do comprehensive evaluations so they will be prepared to examine an organ system in greater detail when necessary. But we also need to help them understand how to use their tools wisely and efficiently. An example where this is done correctly is in the operating rooms. Surgeons use only the tools in their toolkit that they need during the procedure. They may use more or even fewer tools for the next similar case.
Next, I would like to comment on the “chief complaint. “
We were taught in medical school to ask patients a question to ascertain their chief complaint. “Why are you here?” “What brought you to the emergency room?” Why did you come to the office?” What is your main symptom?” While that is important, it’s often going to miss the mark. Sure, it provides a starting point. But almost every illness has a constellation of symptoms and signs, and it’s probably more important to list 2 to 5 main symptoms and signs in the reason for the visit than it is to focus on just one chief complaint. For example, let’s say a patient complains that fatigue is the main thing that’s bothering them. Almost every disease can cause fatigue in some way. But if they complain of fatigue, weight gain, dry skin, and cold intolerance, you have four symptoms that point to hypothyroidism and maybe one or two other things. You’ll spend less time and avoid unnecessary tests. Documentation will tell a better story. I do, however, recommend disallowing patients to start with a long laundry list of complaints. I’ve had patients come to a visit with four pages of 60 to 80 symptoms that they want addressed. There’s no physician on this planet who’s going to be able to do a good job with that type of list. It’s distracting. It’s difficult to decide which storyline is most critical for arriving at a diagnosis. Choose 2 to 5 of the principal problems or things that the patient has noticed, and you’ll be on a path closer to the actual diagnosis than if you start with just one chief complaint and if you wade through fifty complaints. There is an adage that says something to the fact that if you allow them the opportunity, patients will tell you what’s wrong if you can interpret their histories correctly. Thus, it’s to let them speak while you guide your questions to collect those historical facts that color the most important symptoms and signs as you navigate toward the diagnosis. If I may use an analogy to sailing and flight, one can identify their precise location with 3 to 4 reference points. You don’t need 50. That would take too much time, and my time you figured it out using that many points. You’ve moved to a different location. Medicine is much the same way. I don’t need 50 symptoms. 3 to 4 are usually enough.
The differential Diagnosis
One must establish a differential diagnosis, which is a list of things that it could be based on the history and physical. Then, diagnostic tests can be ordered. Clearly, some patients have more than one disease process at a time or at least one disease that causes a number of other system malfunctions. It’s easier for the experienced clinician to understand the associations, but you’d be surprised how often even the best doctors have failed to recognize that the patient’s hyperlipidemia, diabetes mellitus, hypertension, weight gain, and depression are not just a series of individual diagnoses, but might be related to underlying hypercortisolism for which there is also a differential diagnosis related to causality.
Lastly, for unclear reasons, the art of the differential diagnosis has all but disappeared.
There should be more emphasis on teaching the importance of this and on how to construct a differential diagnosis, because it is a navigational pathway in medicine that will serve doctors and patients well. Why does it seem to have been abandoned? It’s probably because physicians are busy, have little time to think when they are with patients, and the evaluative process takes time and can be costly. Further, the differential diagnosis must be based on breadth and depth of medical knowledge. It takes years to acquire the requisite knowledge through the practice of medicine. Learning to work through it based on relevant findings during history and physical and review of laboratory studies takes a particular mindset and, in my experience, not all physicians possess the skills and abilities to do so. The differential diagnosis is difficult to teach. It has to be learned. There has to be a conscious decision by healthcare providers to develop the skills and abilities to establish differential diagnoses and use them effectively to narrow down the list of possibilities for what is ailing a patient.
© 2026, J D Faccinetti. All rights reserved.