All the statins and lipid-lowering drugs in the world may not do Mrs. Johnson any good if her doctor misses a lump on her annual clinical breast exam. And that's more likely to happen if she's obese.
That's why two physician educators at the University of Pittsburgh are saying that physicians-in-training need more and better education on how to adapt their physical examination skills to the growing number of Americans who are obese. In a commentary published online Dec. 29 in JAMA: The Journal of the American Medical Association, the two co-authors present a number of these adaptations and recommend that medical students and residents receive formal instruction about them as part of their training.
Despite a doubling of the prevalence of obesity just in the past generation, "Medical education about physical diagnosis skills for obese patients has not kept pace with the obesity epidemic," say co-authors Ann Willman Silk, M.D., and Kathleen McTigue, M.D., M.P.H., in their article, "Re-examining the Physical Examination for Obese Patients(jama.jamanetwork.com)."
Currently, they note, physical diagnosis texts provide little advice on how to overcome the limitations of the physical exam in patients who are obese. Even obesity management handbooks usually include only a cursory description of how to perform the exam, focusing instead on how to detect obesity-associated disease, such as acanthosis nigricans or adiposis dolorosa.
According to the authors, physically examining a person who is obese -- that is, one who has a body mass index, or BMI, of 30 or greater -- is particularly challenging because the primary techniques of inspection, palpation, auscultation and percussion can be undermined when internal structures are encased in a thick layer of adipose tissue.
Caring for obese patients is challenging for other reasons, as well, say the authors.
Because of both patient and physician factors, obese women are less likely than their normal-weight counterparts to obtain regular mammograms and to undergo routine Pap tests. Some physicians, for example, are reluctant to perform breast and gynecological examinations on obese women because they think the exams are difficult or inadequate, the authors say.
Yet it's especially important to perform clinical breast exams in this population, they note, because obesity is a specific risk factor for breast cancer. But the exam has to be done correctly.
"An association between higher BMI and nonpalpable breast cancers may suggest that the clinical breast examination lacks sensitivity in women with large breasts," say the authors. "Any consequences of suboptimal clinical breast examinations are then compounded by the inadequacy of screening mammography in the obese population.
"This scenario provides one possible explanation for the association between increasing BMI and more advanced-stage breast cancer at diagnosis."
The authors point out that physicians who know more about obesity-specific examination techniques have less difficulty in palpating masses during breast and pelvic examinations, suggesting that these are "teachable skills."
They offer a number of practical tips on how to perform the physical examination in patients who are obese, including the following examples:
- Because thick chest walls may obscure heart sounds during the cardiovascular exam, palpate the carotid pulse at the same time. Ask sitting patients to lean forward to bring the heart closer to the chest wall. Ask recumbent patients to raise their arms above their heads to spread out chest-wall soft tissues. In addition, a handheld Doppler device can be used to check the patient's pulse.
- For the clinical breast exam, spend at least three minutes examining each breast with the patient in a lateral decubitus position.
- Because patients may be embarrassed to report skin conditions, ask about problem areas and do a thorough skin examination, paying special attention to intertriginous folds.
The authors also suggest that obese standardized patients be included in medical training and that physical diagnosis textbooks include illustrations of obese patients, address differences in the physical examination of these patients and provide suggestions for adapting the exam to this population.