The Physical Exam
Source transcript: The Physical Exam - Raw Transcript
I have been thinking about the physical exam recently because, well, it is physical.
I have been wiring up and testing a live dictation module on my computer using synthetic data. For a while, I was skeptical of this whole ambient dictation idea. I thought it might require me to talk to the AI, or alter the visit in some awkward way. But the more I test this, the more I think that is probably wrong.
I built a small demo version here: live-transcription-to-note-demo. It only uses synthetic data.
For most of a visit, the AI can likely conform to the doctor, not the other way around.
Let's look at the parts of the visit.
History-taking is already spoken.
Assessment and plan is often spoken too, especially when you explain your reasoning to the patient.
So a good visit already contains much of the note. If the audio is good enough, live transcription may actually be more accurate than post-visit dictation or writing because more of the visit is captured in real time rather than reconstructed afterward.
There will still be editing. There will still be cleanup. There will still be judgment. But there is something very enticing about the idea of leaving the room with 95% of the note already done.
And in some ways, the quality of the note might be better.
Also, it is not a bad thing to go through the plan out loud with the patient while you are in the room. The patient hears your thinking. You hear yourself explain it. The transcript captures the actual conversation. The note becomes less of a separate clerical task and more of a record of what actually happened.
But then there is the physical exam.
The physical exam is the part that live transcription cannot really do unless you say out loud what you are doing.
Most of the exam is not naturally verbal. You listen. You look. You press. You move a joint. You watch someone walk. You feel for tenderness. You notice whether the body in front of you matches the story you have been told. None of that enters the transcript unless you narrate it.
At first, that seems awkward. But maybe it is not as strange as it sounds.
"Your lungs sound clear."
"Your heart rhythm is regular."
"I do not feel a thyroid nodule."
"Your abdomen is soft and not tender."
That is not bad medicine. It may actually be good medicine. Patients may like knowing what we are doing and what we are finding. In that sense, narrating the exam would not really be talking to the AI. It would be talking to the patient. The AI would just happen to capture it.
But it still does not fully solve the problem.
The physical exam is not just a section of the note. It is part of the thinking.
See, the history gives you a direction. The exam pushes you toward that direction, away from it, or somewhere else entirely. Sometimes the exam confirms what you already suspected. Sometimes it weakens the story. Sometimes it changes everything.
It is not only a checklist. It is an interaction between the differential diagnosis and the body in front of you.
You can imagine a future where the history is taken by AI, or partially taken by AI. You can imagine a future where the plan is generated, drafted, or refined by AI. I think AI will become increasingly good at synthesizing information and suggesting plans. It may already be 80% of the way there, whatever that means. But I think the last 20% will be harder than people expect. Medicine has a lot of edge cases. There are many situations where what matters is not just generating a cautious plan, but knowing what does not need to be pursued.
Still, the physical exam remains different.
Perhaps it does not have to be done by a doctor in every case. You could imagine an exam specialist. Someone highly trained in physical examination who goes into the room, or even goes to the patient's house, and performs the exam for a remote clinician. Maybe that will exist someday.
But you would have to really trust that exam.
Not just trust that the person checked the box, but trust that they knew what mattered. Trust that they noticed the thing you would have noticed. Trust that the exam was connected to the question being asked.
So, the physical exam may be the thing that keeps office medicine physically grounded, at least for the foreseeable future. History can be spoken. The plan can be spoken. Documentation can increasingly become ambient. But the exam still requires a body in a room with another body.
That may change someday, but for now, the physical exam still matters. It matters not because every exam finding changes management. Not because every annual physical needs to be heroic. Not because the physical exam is somehow pure and everything else is artificial.
It matters because the exam is one of the places where medicine becomes real.
A patient tells you a story. You examine them. You think. You explain the plan.
AI may help capture more of that. It may help organize it. It may make the note better and the workflow less awful, but for now, at least, the physical exam is one place that still requires in-person human contact, and that is what makes it special and unique.
One small process note: when I share these posts on LinkedIn, I am going to start including the raw transcription when one exists. For this post, here is the source transcript.