Our chiropractic education teaches us that 70-90 percent of a patient's diagnosis is derived from the history. The purpose of the physical examination is, in part, to rule out certain conditions. I have no intention to tell doctors how to perform a physical exam or what tests to perform. Those decisions should be left to each physician's clinical judgment. However, I am going to make some recommendations.
As discussed in previous articles, soft tissue injuries do not lend themselves well to hard, objective documentation. The defense bar will capitalize on this fact and focus attention on the lack of this hard evidence. The typical series of questions will be something like this:
Q: "Doctor, how did you arrive at your opinions and conclusions?"
A: " I recorded the patient's medical history and conducted a thorough physical examination. Based on those findings, I ordered some diagnostic imaging."
Q: "Doctor, I noticed in your exam next to 'range of motion', you marked that 'Ms. X could not turn her neck beyond 10 degrees because of pain'. Isn't that true?"
A: "Yes"
Q: "Doctor, isn't it true that you were depending on your patient to tell you whether it hurt or not when she turned her neck?"
A: "Yes"
Q: "Doctor, isn't it true that when a patient tells you something, it is subjective?"
The questions will continue along these lines, with the defense attorney trying to make it seem like everything in your examination is based on the patient's subjective complaints. That is why it is so important to take a thorough history and perform a detailed examination.
The physical, orthopedic and neurological examination should generally be tailored to the individual patient's complaints. If a patient comes in following an automobile accident with a chief complaint of headaches and neck pain, and 50-70 percent of the examination is focused on the lumbar spine, the doctor is setting himself up. The defense attorney steers the deposition or cross-examination away from the patient's injuries and toward the normal findings recorded in the lumbar spine.
Why limit the exam? Some DCs might say that if a person has a problem with their neck, it will cause a compensatory problem in the lower back. I agree with these assertions, yet this type of practice will not "fly" in the medical legal arena. I recommend that the only areas treated are those of chief complaint. A cursory exam can be performed on other areas, but the area should only be treated if objective documentation is demonstrated and the doctor can demonstrate the causal relationship with the accident.
Physical Exam Recommendations
Guy DiMartino,DC,JD
Merrillville, Indiana
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
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While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
