Factors Affecting the Completion of Genitourinary Physical Examinations Prior to Urologic Consultation

INTRODUCTION

A comprehensive history and physical examination is a vital aspect of patient care. Despite patients' urologic concerns, the documentation of genitourinary (GU) examinations of patients for whom a urology consultation has been requested is often inconsistent, incomplete, or simply overlooked. The essentials of a diagnosis lay within the information obtained directly from the patient's bedside, yet as physicians progress into their specialties, this salient feature can be lost:

The medical history is the cornerstone of the evaluation of the urologic patient, and a well-taken history will frequently elucidate the probable diagnosis… .A complete and thorough physical examination is an essential component of the evaluation of patients who present with urologic disease. Although it is tempting to become dependent on results of laboratory and radiologic tests, the physical examination often simplifies the process and allows the urologist to select the most appropriate diagnostic studies.1

Few studies have evaluated whether comprehensive GU examinations are conducted prior to urologic consultations in a tertiary care treatment center. Existing studies are limited by small patient cohorts during short time intervals, making a broad analysis of the trends in examination challenging.2 We sought to determine the occurrence of GU examinations performed on patients before a urologic consultation and to understand which factors influence whether GU examinations are performed. Because of the sensitive nature of GU examinations and the varying comfort level of practitioners in other specialties with the intricacies of such an examination, we hypothesized that both emergency department (ED) and primary inpatient treatment teams would defer a GU examination prior to requesting a urologic consultation and that the likelihood of performing such an examination would be contingent on various demographic variables such as patient sex and age.

RESULTS

A total of 1,596 urologic consultations were ordered during the study period. Patient age ranged from 19-102 years (mean 60.5 years), 66.1% (1,055) of patients were male, and 33.9% (541) of patients were female. The most common reasons for consultation of the 1,596 patients were other (503 [32%]), urinary retention (303 [19%]), urolithiasis (188 [12%]), gross hematuria (178 [11%]), and hydronephrosis (152 [10%]). Table 1 shows the proportion of GU physical examinations stratified by evaluating team and primary reason for consultation. Examples of reasons for consults listed under other included urinary incontinence, phimosis, paraphimosis, and priapism.

DISCUSSION

Physicians are trained early in their education on the value of a physical examination, but the practice of performing and documenting a thorough GU examination appears to be limited.3 Reasons for this limitation could be widespread, including confidence or experience deficits.3 Additionally, prompt and thorough physical examination is a vital resource for diagnosis of various urologic conditions, such as testicular torsion, priapism, or penile fracture. A number of clinical diagnoses can be elucidated with a GU examination, including gross hematuria and hydroceles. Delaying intervention by waiting for imaging before specialty service consultation could compromise patient outcomes.4

As we have become more reliant on laboratory values and various imaging modalities, we have become less reliant on physical examination findings in workup.1 A 1993 study demonstrated that residents spend only 20% of their time in the hospital with patients and spend the majority of their time charting.5 This situation has changed very little, as another study from 2013 showed that residents spend most of their time reviewing records and entering orders.6

Reliability can be thought of as how often numerous clinicians examining the same patient will find a particular sign. Reliability is imperfect in regard to physical diagnosis, but most imaging studies are also deficient. Poor reliability of a physical sign can also undermine its accuracy. However, most diagnostic standards, including computed tomography, ultrasound, mammography, magnetic resonance imaging, and laboratory values, have significant deficiencies in reliability.7 An example can be demonstrated through the use of Wells pretest probability, which is determined by a collection of signs and symptoms a patient presents with and does not include any radiologic or laboratory tests. Studies have shown that Wells pretest probability has a greater reliability than ultrasonography for the diagnosis of deep vein thrombosis/pulmonary embolism.8,9 In the end, all instruments used for medical/surgical workup inherently include some form of subjectivity. To improve reliability in physical examinations, forming good practice habits so that physical examination techniques can be mastered and interobserver agreement can be improved is important, particularly among resident physicians, as they have been shown to continue and reinforce consultation skills that they develop during training.10,11

Our study demonstrates that the preconsult GU examination rate is low, regardless of provider and of the sex and age of the patient. Older female inpatients are least likely to be examined prior to urologic consult, while young male patients in the ED are most commonly evaluated. It is not surprising that females are less likely to be evaluated with a urologic physical examination considering the physical and emotional issues that must be addressed when examining female genitalia, possible equipment constraints, the potential need for a chaperone or access to specific examination rooms with appropriate equipment, and longer examination times compared to patient interactions without initial GU examinations. These examinations can be a challenge for both the clinician and the patient, but techniques and guidelines are available to help abate such concerns.12

We believe that the low rate of preconsult GU examinations identifies an area for improvement in quality of care that needs to be addressed. Improvement could be achieved by including information regarding the need for and importance of GU examinations in the undergraduate medical education curriculum as well as in continuing education programs. Consultations are often indicative of complex patients who may represent a disproportionate burden on healthcare resources.13 Further research into the financial and safety aspects of incomplete consultations should be conducted with the aim of improving patient outcomes.

Despite the strong sample size of our study, some study limitations are important to consider. These include the retrospective nature of the study, the cross-sectional design, and the fact that the consulting physicians may not have documented examinations they performed. Because our study was done at a single academic institution, our findings are not generalizable to community hospitals.

CONCLUSION

Our study indicates that initial GU examinations were omitted in >60% of patients for whom urologic consultation was requested. Whether the variability of preconsult GU examinations directly affects patient care is unknown. Future studies could be aimed at determining whether the omission of preconsult GU examinations negatively affects quality of care.