CLINICAL RESEARCH STUDY

Inadequacies of Physical Examination as a Cause

of Medical Errors and Adverse Events: A Collection
of Vignettes
Abraham Verghese, MD,a Blake Charlton, MD,b Jerome P. Kassirer, MD,c Meghan Ramsey, MD,a
John P.A. Ioannidis, MD, DScd
a
The Program in Bedside Medicine and dStanford Prevention Research Center, Stanford University School of Medicine, Stanford, Calif; bDepartment
of Internal Medicine, University of California, San Francisco; cDepartment of Internal Medicine, Tufts University School of Medicine, Boston, Mass.

ABSTRACT
BACKGROUND: Oversights in the physical examination are a type of medical error not easily studied by chart
review. They may be a major contributor to missed or delayed diagnosis, unnecessary exposure to contrast and
radiation, incorrect treatment, and other adverse consequences. Our purpose was to collect vignettes of
physical examination oversights and to capture the diversity of their characteristics and consequences.
METHODS: A cross-sectional study using an 11-question qualitative survey for physicians was distributed electronically, with data collected from February to June of 2011. The participants were all physicians responding to e-mail or
social media invitations to complete the survey. There were no limitations on geography, specialty, or practice setting.
RESULTS: Of the 208 reported vignettes that met inclusion criteria, the oversight was caused by a failure to
perform the physical examination in 63%; 14% reported that the correct physical examination sign was
elicited but misinterpreted, whereas 11% reported that the relevant sign was missed or not sought.
Consequence of the physical examination inadequacy included missed or delayed diagnosis in 76%
of cases, incorrect diagnosis in 27%, unnecessary treatment in 18%, no or delayed treatment in 42%,
unnecessary diagnostic cost in 25%, unnecessary exposure to radiation or contrast in 17%, and complications caused by treatments in 4%. The mode of the number of physicians missing the nding was 2, but
many oversights were missed by many physicians. Most oversights took up to 5 days to identify, but 66
took longer. Special attention and skill in examining the skin and its appendages, as well as the abdomen,
groin, and genitourinary area could reduce the reported oversights by half.
CONCLUSIONS: Physical examination inadequacies are a preventable source of medical error, and adverse
events are caused mostly by failure to perform the relevant examination.
2015 Elsevier Inc. All rights reserved.
The American Journal of Medicine (2015) 128, 1322-1324
KEYWORDS: Attending rounds; Bedside; Bedside teaching; Diagnostic error; Electronic medical record; EMR; Error;
Medical error; Medical mistakes; Mistakes; Oversights; Patient examination; Physical diagnosis;
Physical examination; Resident; Teaching
SEE RELATED ARTICLE p. 1263

Funding: None.
Conict of Interest: None.
Authorship: All authors had access to the data and a role in writing the
manuscript.
Requests for reprints should be addressed to Abraham Verghese, MD,
Stanford University, Department of Medicine, 300 Pasteur Drive, S102,
Stanford, CA 94305-5110.
E-mail address: abrahamv@stanford.edu

0002-9343/$ -see front matter 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjmed.2015.06.004

According to the Institute of Medicines report entitled To Err

is Human,1 medical errors cause nearly 100,000 deaths per
year. The causes are systemic problems of inadequate organization, a culture of nondisclosure, and cognitive diagnostic
errors.2-4 A potentially important type of error that has been
given meager attention is deciencies in physical examination.
The high-tech transformation of medical care has resulted
in diminishing direct patient-physician interaction. Hospitalists in America might spend only 18% of their on-duty
time in direct patient care,5 and duty-hour restrictions have

Verghese et al

Oversights in the Physical Examination

1323

resulted in Internal Medicine interns spending on average

reported that the relevant sign was missed or not sought, and
only 12% of their time with patients but 40% of their time
12% reported other as the cause of the deciency.
on computer-related tasks.6
Consequence of the physical examination inadequacy
Diminished focus on the physical examination may result in
included missed or delayed diagnosis in 76% of cases,
important errors. We asked physicians to contribute clinical
incorrect diagnosis in 27%, unnecessary treatment in 18%, no
vignettes of oversights and errors in physical examination and
or delayed treatment in 42%, unnecessary diagnostic cost in
adverse consequences that resulted
25%, unnecessary exposure to
from them. This database was
radiation or contrast in 17%, and
CLINICAL SIGNIFICANCE
created to identify the diverse types
complications caused by treatand characteristics of errors that can
ments in 4%.

Most errors in the physical examination
be made relating to the physical
The person thought responsible
that lead to consequences are related to
examination.
for the oversight was most often
not performing an examination.
an intern or resident (reported

Failure to undress the patient and
in 95 of 208 cases or 46%), a
METHODS
primary care physician (84, 40%),
examine the skin is a frequent cause of
We designed an 11-question, quala specialist (79, 40%) or fellow
error.
itative survey for physicians, who
(18, 9%). Though there was no

In a patient with abdominal pain,
were asked to send us vignettes of
multiple choice option available to
failure to examine the groin, rectal area,
known instances of oversights in
implicate ones self as the person
and hernia orices can have dire
physical examination and to answer
responsible, 9 responders (4%)
consequences.
related multiple choice questions.
indicated themselves as the
The study was approved by the
physician responsible.
Stanford University Institutional
The number of physicians
Review Board; the detailed instructions to the respondent and
thought to have missed an important aspect of the examinathe questionnaire can be found online at www.surveymonkey.
tion is shown in Figure 1. The oversight was typically
com/s/8S6DL7V.
discovered within 5 days (Figure 2). When participants
A link to the questionnaire was sent to approximately 5000
were asked to estimate what percentage of practicing
physicians of diverse specialties using a commercial medical ephysicians have made a similar error to the one described,
mail marketing service (MMS Inc, Woodale, Ill), with an estithey estimated it to be >95% in 43 instances (20%),
mated 2800 of these having teaching afliations. In addition, we
50-95% in 42 instances (20%), and 5-50% in 78 oversights
used social media sites to disseminate the link, and we
(37.5%), and less than 5% in 28 instances (28%).
encouraged physicians to share the link. There were no limitaThe list of ndings overlooked is long and diverse, but
tions regarding type of specialty and clinical practice setting.
those that were missed more than 5 times included abdominal
Data were gathered from February to June of 2011. Each
mass/organomegaly (n 21, including 3 pregnancies and
entry was reviewed by 2 physicians. We excluded: entries that
2 distended bladders), diagnostic skin nding (n 15, such as
did not form a vignette (eg, residents dont do rectal exams
caf au lait spots, neurbroma, erythema migrans, syphilitic
often enough); entries missing critical information to form a
lesions, and meningococcemia lesions but not including
vignette (eg, a failure to state what precisely was omitted/
herpes zoster), neurologic ndings (n 18), murmurs/rubs
misinterpreted); entries with 2 or more vignettes combined
(n 13, including 4 missed aortic stenosis, 3 missed
when it became impossible to parse out which one was being
pericardial rubs), lymphadenopathy (n 10), groin hernia
addressed in the multiple choice questions. We corrected a
(n 10) or scrotal/testicular pathology (n 6), signs of
response only when the answer to a multiple choice question
peritonitis (n 10), breast masses (n 9), fracture or
clearly contradicted the vignette, suggesting the respondent
orthopedic nding (n 9), congestive heart failure (n 8),
selected the wrong box (eg, the narrative describes a missed
hernia in a patient with pain because the abdominal examination was not done, but the respondent ticks nding elicited
but misinterpreted in lieu of failure to do relevant exam).

RESULTS
Of the 263 responses received, 55 were excluded; of the 208
remaining responses, 27 were corrected by the criteria
described in Methods.
Sixty-three percent of vignettes reported that the oversight was caused by a failure to perform the physical
examination; 14% reported that the correct physical examination sign was elicited but misinterpreted. Eleven percent

Figure 1 Distribution of number of overlookers for 208

oversights in physical exam.

1324

The American Journal of Medicine, Vol 128, No 12, December 2015

Figure 2 Distribution of time to discovery for 208 oversights

in physical exam.

absent or abnormal pulses (n 6), wound or ulcer (n 6),

bruising (n 6), and herpes zoster (n 5).
Forty-seven oversights involved the skin and its appendages including the breast, 37 were related to the abdominal
examination, 37 involved the cardiovascular system, and 36
involved the groin/genital/rectal area. Supplementary
Table 1 (available online) lists all items that were missed.

DISCUSSION
Recent publications describe the decline of physical examination skills.7-12 Our study highlights the consequences and
suggests that many adverse events are preventable. Our
survey suggests that the major cause for error is simply that
the examination is not performed.12,13 In addition to diagnostic consequences, approximately half of the vignettes
report treatment consequences. Most oversights pertained to
a limited number of overlookers, suggesting that some errors may be remedied if several people examine the patient.
Although the majority of the errors were corrected within 5
days, even a delay of 1 hour might affect patient outcomes.
Examining a patient presenting with a complaint (as
opposed to the routine physical) is a low-cost procedure
that, when done with skill, can avoid the majority of oversights listed. Many diseases involving the skin or the
nervous system cannot easily be diagnosed except by the
examination, and for others the appropriate diagnostic test is
indicated by the examination. The drop-down boxes of the
electronic medical record deceptively suggest every patient
has been thoroughly examined (and therefore can be billed),
but it will be the responsibility of educators and professional
organizations to make sure the electronic medical record
truthfully reects what was done.
A short checklist is suggested by our study: physicians
should seek full exposure of the patient; there must be a
mandate to examine hernial orices and the genital
and rectal areas in acutely ill patients or with pain. Pain
should prompt a search for the lesions of shingles. Nonneurologists need a sound neurologic skill set because imaging does not show the functional decits resulting from a
lesion seen. For diseases like Wernickes encephalopathy or
Bells palsy, imaging may not be diagnostic. Finally, there
should be a greater emphasis on actually performing the

examination. In short, physicians in training must be taught

and evaluated at the bedside to diminish this kind of error.
Our survey was not designed to determine prevalence but
to generate an anthology of physical examination oversights
along with their characteristics. The vignettes are subject to
recall and response biases. We set no time limitation on reports and did not ask responders to specify where they practiced medicine. Finally, even though we contacted thousands
of physicians, only a small minority contributed vignettes,
suggesting a cultural reluctance to admit and share errors,
unlike for example in the aviation industry. We as physicians
might work in an ignorance trap in which our physical examination oversights are rarely reported back to us.
Diligence in actually teaching and performing the physical examination and continuing efforts to improve bedside
skills would diminish one kind of medical error and its
consequences for the patient.

ACKNOWLEDGMENT
The authors thank Ralph Horwitz, MD, for his encouragement
of the First Stanford Symposium on Bedside Medicine in
2009, and for his helpful discussions in planning this study.

References
1. Kohn KT, Corrigan JM, Donaldson MS. To Err Is Human: Building a
Safer Health System. Washington, DC: National Academy Press; 1999.
2. Kassirer JP, Kopelman RI. Cognitive errors in diagnosis: instantiation,
classication, and consequences. Am J Med. 1989;86(4):433-441.
3. Graber ML, Franklin N, Gordon R. Diagnostic error in internal
medicine. Arch Intern Med. 2005;165(13):1493-1499.
4. Singh H, Graber ML, Kissam SM, et al. System-related interventions
to reduce diagnostic errors: a narrative review. BMJ Qual Saf.
2012;21(2):160-170.
5. OLeary KJ, Liebovitz DM, Baker DW. How hospitalists spend their
time: insights on efciency and safety. J Hosp Med. 2006;1(2):88-93.
6. Block L, Habicht R, Wu AW, et al. In the wake of the 2003 and 2011
duty hour regulations, how do internal medicine interns spend their
time? J Gen Intern Med. 2013;28(8):1042-1047.
7. Feddock CA. The lost art of clinical skills. Am J Med. 2007;120(4):
374-378.
8. Rahmani S, Ring BN, Lowe R, et al. A pilot study assessing knowledge
of clinical signs and physical examination skills in incoming medicine
residents. J Grad Med Educ. 2010;2(2):232-235.
9. Willett LL, Estrada CA, Castiglioni A. Does residency training
improve performance of physical examination skills? Am J Med Sci.
2007;333(2):74-77.
10. Sharma S. A single-blinded, direct observational study of PGY-1 interns and PGY-2 residents in evaluating their history-taking and
physical-examination skills. Perm J. 2011;15(4):23-29.
11. Jauhar S. The demise of the physical examination. N Engl J Med.
2006;354(6):548-551.
12. Ortiz-Neu C, Walters CA, Tenenbaum J, Colliver JA, Schmidt HJ.
Error patterns of 3rd-year medical students on the cardiovascular
physical examination. Teach Learn Med. 2001;13(3):161-166.
13. Bordage G. Why did I miss the diagnosis? Some cognitive explanations
and educational implications. Acad Med. 1999;74(10 suppl):S138-S143.

SUPPLEMENTARY DATA
Supplementary table accompanying this article can be found
in the online version at http://dx.doi.org/10.1016/j.amjmed.
2015.06.004.

Verghese et al

Oversights in the Physical Examination

Supplementary Table 1 Complete List of Items Missed as

Reported in Returned Questionnaires
Missed skin nding of subcutaneous emphysema
Missed pulse absence in ischemic foot
Missed pregnancy with twins before hysterectomy
Missed hip fracture labeled as right lower quadrant pain
Missed Bells palsy
Missed liver mass, abdominal mass in cholangiocarcinoma
Missed funduscopic nding of cupping
Missed strangulated groin hernia in small bowel obstruction
Missed incarcerated femoral hernia
Missed crackles in a patient with pulmonary edema
Missed nger pressure necrosis on microvascular free ap
Missed peritoneal signs and free air on plain lm
Missed peritonitis in patient with gangrenous perforated gall
bladder
Missed adenopathy and therefore chronic lymphocytic leukemia
Missed thyromegaly in patient with tachycardia
Missed strangulated hernia
Missed fungating breast mass
Missed pelvic examination and therefore missed tubo-ovarian
abscess
Missed pregnancy by missed gynecologic examination in patient
with seizures
Missed pyoderma gangrenosum in skin
Missed Fourniers gangrene in groinno genital examination
Missed clonus and hyperreexia
Missed abdominal examination nding of tenderness and Grey
Turner signs
Missed neurobroma and caf au lait spots
Missed large abdominal mass
Missed heart failure signs of cardiomyopathy after u in a young
person
Missed pulse extremity examination, missed Buergers
Missed testicular mass in teen
Missed massive splenomegaly
Missed second cervix
Missed abrasion on forehead, clue to subdural
Missed bruising signs of abuse in child
Missed prostate mass with elevated prostate-specic antigen
Missed decreased pulses, arterial occlusion in elderly man after hip
fracture
Missed strangulated femoral hernia in 88-year-old with emesis
Missed loud bruit in patient with renal failure and hypertension
Missed ruptured spleen after trauma
Missed ectopic pregnancy because no pelvic examination done
Missed obvious congestive heart failure (CHF) signs labeled as
bronchitis
Missed rotatory and vertical nystagmus in patient with basilar
artery aneurysm
Missed abdominal examination, old scar mislabeled as hernia, scar
and patient operated on for recurrent hernia and nothing found
Missed pulses in patient with peripheral vascular disease
Missed tuberculosis signs in chest
Missed vital sign of tachypnea on rst visit in a patient later found
with bacteremic pneumonia
Missed adenopathy in lymphoma
Missed clavicle fracture, labeled rule out myocardial infarction
Missed the tan of hemochromatosis

1324.e1
Supplementary Table 1

Continued

Missed femoral fracture

Missed acute myocardial infarction by focusing on neck pain, ear
pain
Missed hyperreexia and cord compression in Potts disease
Missed rectal and missed prostatic abscess
Missed supraclavicular mass in lung cancer
Missed splenomegaly and delayed diagnosis of chronic
myelogenous leukemia
Missed psoriasis and its signs
Missed groin cellulitis
Missed dislocated shoulder on examination
Missed adenopathy in germ cell tumor
Missed marked pallor in elderly anemic
Missed pulsatile abdominal aneurysm
Missed adenopathy in patient with Waldenstroms disease
Missed penetrating foreign body in vaginal stula
Missed gastric bypass scar in patient with malnutrition and
beriberi
Missed signs of CHF in a young patient
Missed femoral hernia in patient with vomiting
Missed signs of hypothyroidism and neck scar in unresponsive
patient
Missed retinal lesions in a child with poor vision
Missed signs of myocarditis and CHF, especially the tachycardia in
a child
Misconstrued bruit from an aortofemoral bypass as a cardiac
murmur
Missed obvious CHF signs
Missed obvious pregnancy and labor
Missed huge spleen in cirrhosis
Missed previous appendectomy scar and made diagnosis of
appendicitis again
Missed ulnar nerve transection after trauma
Missed male breast mass
Missed distended bladder
Missed incarcerated hernia
Missed breast mass and metastases
Missed zoster presenting as abdominal pain
Missed femoral hernia
Missed orchitis and diagnosed it as hernia
Missed aortic stenosis murmur preoperatively
Missed breast mass
Missed anus present in patient stated to have abdomino-perineal
resection, when they had Hartman procedure
Missed prolapsing rectal cancer, rectal examination not done
Missed incarcerated groin hernia
Missed bruises of abuse
Missed large melanoma over scapula
Missed hoarseness, pufness, and signs of hypothyroidism
Missed decubitus ulcer causing back pain
Missed leg ulcers and sores as a cause of fever in alcoholic
Missed skin ndings of secondary syphilis
Missed hip fracture in patient who could not walk
Missed gouty nodules
Missed breast mass
Missed mucor wound on hand in immunocompromised patient
Missed zoster in patient with chest pain
Missed foot ulcer in diabetic with fever

1324.e2
Supplementary Table 1

The American Journal of Medicine, Vol 128, No 12, December 2015

Continued

Missed signs of Parkinsons in elderly being worked up for falls

Missed lymph node in a patient with breast cancer
Missed abdominal mass lymphoma in patient complaining of pain
Missed skin ash leaf macule in child with hypertension
Missed anterior cruciate ligament tear with classic signs
Missed giant ovarian cyst, labeled as ascites
Missed giant ovarian cyst again thought to be ascites
Missed loud murmur of ruptured mitral valve chordae tendinae
Missed murmur and signs of subacute bacterial endocarditis
Missed cutaneous abscess in compromised patient with fever
Missed obvious CHF in 33-year-old with cardiomyopathy
Missed appendicitis signs
Missed strangulated hernia
Missed Downs syndrome on examination in 6 month old
Missed acute central vein occlusion in patient with decreased
visionno fundoscopy done
Missed anal cancer said to be hemorrhoids
Missed peritonitis signs in patient with Crohns
Missed dentures in mouth during intubation
Missed signicant murmur of mitral stenosis, called it aortic
stenosis
Missed abdominal mass turned out to be lymphoma
Missed aortic stenosis in preoperative examination
Missed scrotal mass until after surgery for abdominal mass. Was
testicular tumor with metastases
Missed supraclavicular nodes in patient with lung cancer
Missed hyperreexia and clonus from epidural abscess
Missed adenopathy in non-Hodgkins lymphoma with fever of
unknown origincalled a hernia
Missed neck nodes
Missed pelvic inammatory disease because no pelvic examination
done
Missed gunshot entrance wound in emergency room
Missed large abdominal masses in patient with bloating
Missed pregnancy in patient with large belly
Missed signs of CHF in patient presenting with scrotal swelling
Missed liver laceration after trauma because focus on head
Missed enlarged tonsil that was cancer
Missed clavicle fracture in patient with syncope
Missed ecchymosis in patient from a fall, and the left arm pain
assumed to be cardiac
Missed contact dermatitis
Missed constrictive pericarditis signs
Missed breast mass in patient with shoulder pain
Missed breast mass in patient with deep vein thrombosis
Missed rapid growth in head circumference
Missed splinters and signs of subacute bacterial endocarditis
Missed systolic murmur cardiac, labeled carotid bruits
Missed pericardial rub and pericarditis
Missed zoster rash
Missed hip disease as a cause of joint pain
Missed femoral pathologic fracture in patient with knee pain
Missed large liver in patient with diabetic ketoacidosis
Missed zoster as cause of chest pain
Missed watch battery in umbilicus in child
Missed purulence in tonsils
Missed normal ear examination labeled as perforation by not doing
pneumatic otoscopy

Supplementary Table 1

Continued

Missed breast mass in patient with chest pain and metastasis

Missed pregnancy, called it constipation
Missed meningococcemia skin lesion in patient with fever
Missed CHF ndings in patient with postpartum cardiomyopathy
Missed hoarseness and laryngeal mass in patient labeled asthma
Missed rectal mass by gastrointestinal consultant after primary
care physician feels masssigmoidoscopy negative, but tumor
develops
Missed appendicitis by focus on chest
Missed rales and crackles
Missed obvious pleural effusion, no examination
Missed signs of myasthenia in patient with weight loss
Missed signs of bowel obstruction
Missed signs of mitral regurgitation from torn leaet
Missed hepatomegaly and hepatocellular carcinoma in patient with
vague symptoms
Missed metastatic node from breast cancer in patient with weight
loss
Missed stone in urethra causing recurrent urinary tract infection
Missed pelvic examination in adolescent and missed pelvic
inammatory disease
Missed radiculopathy causing abdominal pain
Missed signs of peritonitis
Missed fungating breast mass
Missed abdominal mass in patient with back pain
Missed pelvic examination and missed procidentia
Missed skin signs of calcinosis in patient with mixed connective
tissue disease
Missed breast mass in patient being worked up for metastasis
Missed skin erythema migrans in patient with Bells palsy
Missed abnormal pulses of combined aortic stenosis/aortic
regurgitation and focused on treating high blood pressure and
pulse pressure
Missed aortic stenosis murmur
Missed abdominal mass, expanding aortic aneurysm in patient with
abdominal pain
Missed pericardial friction rub in chest pain
Missed nasal septal hematoma
Missed scrotal infection in diabetic
Missed Korsakoffs signs in many neurologic examinations
Missed zoster in patient with chest pain who had coronary
angiogram
Missed pelvic examination and missed ovarian cyst
Missed adenopathy and hepatomegaly in patient with anemia and
weight loss
Missed inammatory knee effusion in intensive care unit patient
with fever
Missed distended bladder labeled abdominal mass
Missed rectal examination and therefore missed prostatitis
Missed doing pulsus paradoxus in patient with tamponade
Missed abnormal decreased pulse and blood pressure in one arm
Missed purulence around IV catheter as cause of fever
Mistaken diagnosis of peritonitis, bias from x-rays showing
pneumatosis intestinalis
Missed lytic lesions as cause of left-sided weakness in limbs
Missed CHF signs
Missed purulence at bone marrow biopsy site in patient with fever
Missed clubbing in patient with shoulder pain who has lung cancer

Verghese et al

Oversights in the Physical Examination

Supplementary Table 1

Continued

Missed hernia because of missed groin examination

Missed edema from hypoproteinemia labeled CHF
Missed peritonitis and perforation
Missed murmur of critical aortic stenosis
Missed buttery bruises of factitious injury
Missed neurogenic bladder
Missed costochondritis in patient labeled as rule out myocardial
infarctions
Missed epididymitis in patient with abdominal pain
Missed scrotal examination
Missed erythema migrans in patient with fever and headache
Missed large abdominal mass on both pelvic and seated abdominal
examination
Missed embolic arterial occlusion
Missed uremic calciphylaxis in patient on dialysis

1324.e3