PGY1 Pharmacy Resident
University of Maryland Medical Center
The physical exam has been considered an essential component of education for medical students and residents since the inception of medicine. It is also essential for other healthcare professionals including nurses and physician assistants. Traditionally, pharmacists have not been integrated into the physical exam process. However, given the national shortages in primary care physicians and pharmacists advocating for provider status, pharmacists have expanded their role to include “primary care” type services. This includes the ability to measure and interpret blood pressure, heart rate, administer vaccinations, triaging symptoms that warrant emergency intervention, and perform physical examination. Especially over the last 20 years, with the expansion of ambulatory care services provided by pharmacists, the ability to competently perform and evaluate physical examinations has become vital for pharmacists. In fact, in 2006, the Accreditation Council for Pharmacy Education (ACPE) added addressing physical assessment techniques in its standards for pharmacy school curriculums. Furthermore, the Pharmacy Practice Supplement to the Center for Advancement of Pharmaceutical Education (CAPE) included the ability to perform and evaluate the physical assessment to the educational outcomes expectations in 2004.
The aspects of the physical exam that pharmacists across practice settings are likely familiar and more comfortable with include blood pressure readings, point of care blood glucose, and diabetic foot examinations. However, examining a patient in general involves three major components including (1) interview and health history, (2) survey and vital signs, and (3) the physical exam itself. The physical examination involves the entire body and can be comprehensive or more focused. Pharmacists will often perform a more focused exam based on the patient’s reported concerns and presenting symptoms. This makes an accurate and comprehensive collection of health history and symptomatology especially important. As described by Dr. Melanie Dodd at the 2019 American Society of Health-System Pharmacists (ASHP) conference, various techniques are employed in the physical examination and heavily involve the use of the performer's hands including “inspection, palpation, percussion, and auscultation. ” After her presentation, the attendees broke out into session to further explore four of the major areas of the physical examination: musculoskeletal, neurological, cardiovascular, and pulmonary.4 These sessions included performing a wide variety of assessments including fall risk determination, pupil dilation, listening to lung vibrations, and orthostatic measurements.4
Given the involved and complex nature of the physical examination, the attainment of such skills requires formal instruction and constant practice. As such, pharmacy schools have begun to incorporate these skills into their curricula. Furthermore, the practice setting of the pharmacist highly influences the differential importance of different aspects of the exam. For example, a pharmacist practicing in ambulatory care might focus more on physical exam findings that require chronic disease state management as compared to a pharmacist practicing in emergency medicine who would tailor the physical exam to identify problems requiring prompt intervention.
Practically, performing the physical exam provides an avenue for pharmacists to provide direct patient care and document and bill for their services. This is essential when considering efforts for pharmacists to be granted provider status. Pharmacy curricula should incorporate physical examination skills to prepare students for the evolving role of pharmacists in healthcare, including the knowledge and confidence for performing and interpreting physical exams. From a public health standpoint, pharmacists providing these services can increase access to care for patients in more remote areas and/or patients who have limited access to primary care physicians. This can have profound impacts in detecting and triaging various conditions that can be effectively managed with medications such as hypertension and hyperlipidemia, potentially mitigating more serious consequences of these disease states being untreated such as myocardial infarction or stroke. In the long term, this can decrease health inequity and decrease medical costs associated with high disease burden.
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