-Am
J Psychiatry
135:8,
Psychiatrists BY CHARLES
August
1978
and
Physical
W. PATFERSON,
BRIEF
Examinations:
A Survey
M.D.
RESU
Alumnifrom the 1965 -1974 psychiatric residency classes at the Los Angeles County-University of Southern California Medical Center were surveyed about their individualpractices regarding physical examinations. Ninety-eight of155 alumni returned anonymous questionnaire None of the respondents routinely performedphysical examinations on new outpatients. The 61% who had inpatient practices usually delegated the hospital admission physical examination.
LTS
Of the 155 questionnaires mailed, 98 (63%) were returned within 6 weeks. The group who received the questionnaires averaged 4.6 years out of training, and those who responded averaged 4.5 years. All of the respondents were currently practicing psychiatry. Eighty-seven percent were in full- or part-time private practice, 68% had some form of university appointment, 46% were Board certified, and 28% had practiced medicine before training in psychiatry. Of those who indicated type of practice (N=94), 69% had both
the
.
inpatient FUTURE ROLE of speculative topic. One chiatny should identify origins and that psychiatrists ognizably as physicians
the psychiatrist is a recurring viewpoint advocates that psymore closely with its medical should perform more nec(1 , 2). Should such a neorienta-
THE
tion occur, dude such
the practice styles traditional medical
of psychiatrists who activities as physical
exex-
aminations would be altered. Psychiatric textbooks discuss physical examinations (3, 4), but little has been written about whether or not practicing psychiatrists actually perform physical examinations. This study is based on a survey of practicing psychiatrists and is an assessment of the factors that shape individual policies about physical examinations.
METHOD
Structured questionnaires were mailed to 155 physicians who had completed at least 2 years of psychiatric training at the Los Angeles County-University of
Southern
California
classes
who
period
from
Medical
had
completed
1965
to 1974.
Center training
The
development with respect were asked
Dr.
Professor
is Assistant
Southern California dress reprint requests
County-USC Calif. 90033.
Medical
1934
members the
Hospital
Los Angeles, Hospital,
Place,
0002-953X/78/0008-0967$0.35
of
10-year pracexamianony-
Los
Los
outpatient
practices
The
practices
psychiatrists
were
ignee
routinely
performed
new
outpatients.
Ofthe
asked
Calif. AdAngeles
Angeles,
© 1978
whether
a physical
31%
had
out-
they
or a des-
examination
94 psychiatrists
who
on
answered
this question, none routinely performed them. Sixteen (17%) routinely sought them, however. Two respondents mentioned that although they did not personally perform physical examinations, their patients were primarily referred by other physicians. New inpatients are customarily required to have a physical examination. Eighty of the respondents com-
mented
on their
individual
customs
regarding
admis-
sion physicals. Of these, 69% indicated that they never personally performed the routine admission physical examination, 16% said seldom, 9% said usually, and
6% said always. Psychiatrists out of training less than the group average of4.5 years were three times more likely
to
were
the
do
the
older
admission
alumni
physical
(21%
overwhelming majority physical examination
who were delegated to were internists (63%), (16%), other psychiatrists pediatricians
cians
perform
name
listed
four
than
although
the
groups delegated the The other physicians
and
“others”
the psychiatrists admission
choices
themselves
6%),
perform these examinations family!general practitioners or psychiatric residents
(3%),
why the
versus
in both to others.
(4%).
had
physicals,
for reasons,
tunity to add other reasons. to indicate as many reasons ally. A total of 186 reasons or
and
only.
To determine
of
University
and
patient
(15%),
included
and type to physical to respond
of Psychiatry,
School of Medicine, to him at Psychiatric
Center,
as over
questionnaire
items on professional tice as well as policies nations. The physicians mousby.
Patterson
COMMUNICATIONS
other the
with
physi-
question-
a fifth oppor-
Subjects were encouraged as applied to them personwere received from 83 re-
spondents (2.2 per respondent). Of the respondents who selected from the four offered reasons, 58% had someone else do the physical to save time (efficiency), 53% no longer felt competent, 49% did it to avoid transference and!or countertransference problems, American
Psychiatric
Association
967
BRIEF
Am
COMMUNICATIONS
Training program psychiatrists’s
and 42% did not like performing physical examinations. Twenty-two percent gave additional reasons. These included the fact that trainees or others were
the
assigned
ten required
to do physical
examinations,
tab requirements
that
ternist,
potential
to
avoid
to keep patients Respondents sons cians
the
to satisfy
physical
be done
given their usual reason perform the physical
by an inand
physical patients.
on physical problems. to select from the rea-
entrusted
medicolegal
from focusing were also asked
aminations.
hospi-
problems,
for having examination.
other physiThe most
of psychiatric patients because of potentially
sequences. To determine ical examination actually
under adverse
whether performing leads to additional
nc problems as feared, port any such problems
respondents they had
certain con-
a physpsychiat-
were asked experienced
their training and!on practice. Since the vast majority of respondents delegated physical examinations, nesponses were few. Nevertheless, 13% ofthose who responded recalled problems , including premature transference development, difficulties with transference eroticization, incorporation into delusions of sexual assault, excessive discussion offeelings rebated to the examination (as a resistance), paranoid fears related to rectal physical
those
or
ophthalmoscopic complaints
who
recalled
practice
for
only
marked
that
the
examinations, dependency.
masking
adverse
consequences
1 on 2 years.
risk
was
and later Half of
Two
had
been
respondents
in re-
exaggerated.
others. The
are
the role
tasks is
generally physical
associated
with
examination
of
the the
physipatient.
nostic importance status examination. physical findings
is attached to the history and mental Perhaps this paucity of psychiatric partially explains why none of the re-
spondents routinely on new outpatients. reasons also appear ence/countentransference of diminished
performed physical examinations From this survey, however, other contributory: to avoid transferproblems, to save time, feelcompetence,
such examinations, and referring physician.
968
previous
dislike
of performing
examination
by the
inon
care
was
years
were
atti-
shaped
for
performing
physicals
by at
mentioned
often
seem
to prefer
findings,
since
as
imposing
viewed
inpatients
without
additional
medical
by
additional
directly toward may reflect the
positive diagnoses
experiences
not
becoming a psychiatrist. local workload on may
one of many reasons for selecting reer. Adverse transference!countertransference
psychiatry
be
as a caproblems
may have occurred, although the practice of avoiding physical examinations prohibits measuring the seriousness and frequency of the problem and probably reduces the potential magnitude considerably. The fact that half of the respondents who recalled adverse consequences had been in practice for only 1 or 2 years may indicate that these problems are more com-
than
reported.
In that
examination
may
event, be
having
others
The
their
serve
the
skills
in
resulting to
performing
“disuse
diminish
psychiatrist
physical
atrophy”
the
do the
important.
For whatever reasons, the medical practice of the psychiatrists surveyed are structured
From these examinations come the data necessary for making many clinical diagnoses. Physical examinations may seem unnecessary to psychiatrists because of the paucity of physical signs associated with the “functional” disorders. Consequently, increased diag-
ings
admitted physicals
training
examinations
cen-
perform
subsequent
in these
to ex-
medical
for newly performed
whose
Thus,
physical
contributing This attitude
ish cian’s
at our
to routinely
only often
admissions
dislike
physical
mon
DISCUSSION
1978
42% of the respondents is often evident early in training. Residents assigned to inpatient wards sometimes view the physical examination as an onerous and timeconsuming task, done primarily because it is required.
physical
Of
program
physicians
to others.
toward
August
least two institutional messages: first, that routine physical examinations were important only in certain psychiatric settings (e.g., with inpatients) and, second, that physical examinations could be performed by
They
to reduring
training
resident
inpatient
135:8,
practices may also contribute eventual avoidance of physical
examinations Also, residents
tudes
common reason was to avoid transference and!or countertransfenence problems (28%). Other reasons included no longer feeling competent (24%), to save time (22%), dislike ofdoing physicals (12%), and “othen” reasons (14%). Menningen (5) advised caution in performing physical examinations circumstances
new
The
J Psychiatry
customs to dimin-
examinations.
of these
personal
and
skills
public
may
identity
of
as a physician.
REFERENCES 1. West 2.
Li:
The
130:521-528, Ludwig AM:
future
ofpsychiatric
1973 The psychiatrist
education. as physician.
Am i Psychiatry JAMA
234:603-604,
1975 3.
Hollender nc practice,
MH, in
Wells CE: Medical The Comprehensive
2nd ed, vol 1. Edited 4. 5.
by Freedman
assessment Textbook
AM,
Kaplan
of
in psychiatPsychiatry,
HI, Sadock
Bi.
Baltimore, Williams & Wilkins Co. 1975, pp 780-781 Redlich FC, Freedman DX: The Theory and Practice of Psychiatry. New York, Basic Books, 1966, pp 2 11-212 Menninger KA: A Manual for Psychiatric Case Study, 2nd ed.
New
York,
Grune
& Stratton,
1962,
pp 46-52
J Psychiatry
135:8,
Psychiatrists BY CHARLES
August
1978
and
Physical
W. PATFERSON,
BRIEF
Examinations:
A Survey
M.D.
RESU
Alumnifrom the 1965 -1974 psychiatric residency classes at the Los Angeles County-University of Southern California Medical Center were surveyed about their individualpractices regarding physical examinations. Ninety-eight of155 alumni returned anonymous questionnaire None of the respondents routinely performedphysical examinations on new outpatients. The 61% who had inpatient practices usually delegated the hospital admission physical examination.
LTS
Of the 155 questionnaires mailed, 98 (63%) were returned within 6 weeks. The group who received the questionnaires averaged 4.6 years out of training, and those who responded averaged 4.5 years. All of the respondents were currently practicing psychiatry. Eighty-seven percent were in full- or part-time private practice, 68% had some form of university appointment, 46% were Board certified, and 28% had practiced medicine before training in psychiatry. Of those who indicated type of practice (N=94), 69% had both
the
.
inpatient FUTURE ROLE of speculative topic. One chiatny should identify origins and that psychiatrists ognizably as physicians
the psychiatrist is a recurring viewpoint advocates that psymore closely with its medical should perform more nec(1 , 2). Should such a neorienta-
THE
tion occur, dude such
the practice styles traditional medical
of psychiatrists who activities as physical
exex-
aminations would be altered. Psychiatric textbooks discuss physical examinations (3, 4), but little has been written about whether or not practicing psychiatrists actually perform physical examinations. This study is based on a survey of practicing psychiatrists and is an assessment of the factors that shape individual policies about physical examinations.
METHOD
Structured questionnaires were mailed to 155 physicians who had completed at least 2 years of psychiatric training at the Los Angeles County-University of
Southern
California
classes
who
period
from
Medical
had
completed
1965
to 1974.
Center training
The
development with respect were asked
Dr.
Professor
is Assistant
Southern California dress reprint requests
County-USC Calif. 90033.
Medical
1934
members the
Hospital
Los Angeles, Hospital,
Place,
0002-953X/78/0008-0967$0.35
of
10-year pracexamianony-
Los
Los
outpatient
practices
The
practices
psychiatrists
were
ignee
routinely
performed
new
outpatients.
Ofthe
asked
Calif. AdAngeles
Angeles,
© 1978
whether
a physical
31%
had
out-
they
or a des-
examination
94 psychiatrists
who
on
answered
this question, none routinely performed them. Sixteen (17%) routinely sought them, however. Two respondents mentioned that although they did not personally perform physical examinations, their patients were primarily referred by other physicians. New inpatients are customarily required to have a physical examination. Eighty of the respondents com-
mented
on their
individual
customs
regarding
admis-
sion physicals. Of these, 69% indicated that they never personally performed the routine admission physical examination, 16% said seldom, 9% said usually, and
6% said always. Psychiatrists out of training less than the group average of4.5 years were three times more likely
to
were
the
do
the
older
admission
alumni
physical
(21%
overwhelming majority physical examination
who were delegated to were internists (63%), (16%), other psychiatrists pediatricians
cians
perform
name
listed
four
than
although
the
groups delegated the The other physicians
and
“others”
the psychiatrists admission
choices
themselves
6%),
perform these examinations family!general practitioners or psychiatric residents
(3%),
why the
versus
in both to others.
(4%).
had
physicals,
for reasons,
tunity to add other reasons. to indicate as many reasons ally. A total of 186 reasons or
and
only.
To determine
of
University
and
patient
(15%),
included
and type to physical to respond
of Psychiatry,
School of Medicine, to him at Psychiatric
Center,
as over
questionnaire
items on professional tice as well as policies nations. The physicians mousby.
Patterson
COMMUNICATIONS
other the
with
physi-
question-
a fifth oppor-
Subjects were encouraged as applied to them personwere received from 83 re-
spondents (2.2 per respondent). Of the respondents who selected from the four offered reasons, 58% had someone else do the physical to save time (efficiency), 53% no longer felt competent, 49% did it to avoid transference and!or countertransference problems, American
Psychiatric
Association
967
BRIEF
Am
COMMUNICATIONS
Training program psychiatrists’s
and 42% did not like performing physical examinations. Twenty-two percent gave additional reasons. These included the fact that trainees or others were
the
assigned
ten required
to do physical
examinations,
tab requirements
that
ternist,
potential
to
avoid
to keep patients Respondents sons cians
the
to satisfy
physical
be done
given their usual reason perform the physical
by an inand
physical patients.
on physical problems. to select from the rea-
entrusted
medicolegal
from focusing were also asked
aminations.
hospi-
problems,
for having examination.
other physiThe most
of psychiatric patients because of potentially
sequences. To determine ical examination actually
under adverse
whether performing leads to additional
nc problems as feared, port any such problems
respondents they had
certain con-
a physpsychiat-
were asked experienced
their training and!on practice. Since the vast majority of respondents delegated physical examinations, nesponses were few. Nevertheless, 13% ofthose who responded recalled problems , including premature transference development, difficulties with transference eroticization, incorporation into delusions of sexual assault, excessive discussion offeelings rebated to the examination (as a resistance), paranoid fears related to rectal physical
those
or
ophthalmoscopic complaints
who
recalled
practice
for
only
marked
that
the
examinations, dependency.
masking
adverse
consequences
1 on 2 years.
risk
was
and later Half of
Two
had
been
respondents
in re-
exaggerated.
others. The
are
the role
tasks is
generally physical
associated
with
examination
of
the the
physipatient.
nostic importance status examination. physical findings
is attached to the history and mental Perhaps this paucity of psychiatric partially explains why none of the re-
spondents routinely on new outpatients. reasons also appear ence/countentransference of diminished
performed physical examinations From this survey, however, other contributory: to avoid transferproblems, to save time, feelcompetence,
such examinations, and referring physician.
968
previous
dislike
of performing
examination
by the
inon
care
was
years
were
atti-
shaped
for
performing
physicals
by at
mentioned
often
seem
to prefer
findings,
since
as
imposing
viewed
inpatients
without
additional
medical
by
additional
directly toward may reflect the
positive diagnoses
experiences
not
becoming a psychiatrist. local workload on may
one of many reasons for selecting reer. Adverse transference!countertransference
psychiatry
be
as a caproblems
may have occurred, although the practice of avoiding physical examinations prohibits measuring the seriousness and frequency of the problem and probably reduces the potential magnitude considerably. The fact that half of the respondents who recalled adverse consequences had been in practice for only 1 or 2 years may indicate that these problems are more com-
than
reported.
In that
examination
may
event, be
having
others
The
their
serve
the
skills
in
resulting to
performing
“disuse
diminish
psychiatrist
physical
atrophy”
the
do the
important.
For whatever reasons, the medical practice of the psychiatrists surveyed are structured
From these examinations come the data necessary for making many clinical diagnoses. Physical examinations may seem unnecessary to psychiatrists because of the paucity of physical signs associated with the “functional” disorders. Consequently, increased diag-
ings
admitted physicals
training
examinations
cen-
perform
subsequent
in these
to ex-
medical
for newly performed
whose
Thus,
physical
contributing This attitude
ish cian’s
at our
to routinely
only often
admissions
dislike
physical
mon
DISCUSSION
1978
42% of the respondents is often evident early in training. Residents assigned to inpatient wards sometimes view the physical examination as an onerous and timeconsuming task, done primarily because it is required.
physical
Of
program
physicians
to others.
toward
August
least two institutional messages: first, that routine physical examinations were important only in certain psychiatric settings (e.g., with inpatients) and, second, that physical examinations could be performed by
They
to reduring
training
resident
inpatient
135:8,
practices may also contribute eventual avoidance of physical
examinations Also, residents
tudes
common reason was to avoid transference and!or countertransfenence problems (28%). Other reasons included no longer feeling competent (24%), to save time (22%), dislike ofdoing physicals (12%), and “othen” reasons (14%). Menningen (5) advised caution in performing physical examinations circumstances
new
The
J Psychiatry
customs to dimin-
examinations.
of these
personal
and
skills
public
may
identity
of
as a physician.
REFERENCES 1. West 2.
Li:
The
130:521-528, Ludwig AM:
future
ofpsychiatric
1973 The psychiatrist
education. as physician.
Am i Psychiatry JAMA
234:603-604,
1975 3.
Hollender nc practice,
MH, in
Wells CE: Medical The Comprehensive
2nd ed, vol 1. Edited 4. 5.
by Freedman
assessment Textbook
AM,
Kaplan
of
in psychiatPsychiatry,
HI, Sadock
Bi.
Baltimore, Williams & Wilkins Co. 1975, pp 780-781 Redlich FC, Freedman DX: The Theory and Practice of Psychiatry. New York, Basic Books, 1966, pp 2 11-212 Menninger KA: A Manual for Psychiatric Case Study, 2nd ed.
New
York,
Grune
& Stratton,
1962,
pp 46-52
