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Telemedicine: The end of the physical examination can mean losing touch

Because of COVID-19, primary care practice has moved to teleconsultations and the physical examination has fallen out of use. A US doctor muses on the effects of its loss.

Dr Paul Hyman of Mid Coast–Parkview Health in Brunswick, Maine writes in JAMA Network, what is a physical examination worth?

As I stare at a list of my upcoming patient appointments in my primary care clinic and try to decide who shall come into the office despite the coronavirus disease 2019 pandemic, this question paralyses me.

In the 15 years that I have been a physician, the physical examination has always occupied a precarious space for me. As a resident, the reams of information I had on patients before I stepped into their room made it tempting to do the “quick physical exam” that Robert Hirschtick bemoaned in a recently republished essay.

More recently, my accountable care organisation’s emphasis on increasing our volume of Medicare annual wellness visits, which do not require a physical examination, and recommendations from some groups against routine physical examinations in asymptomatic patients has me second guessing why I examine healthy elderly patients.

As our primary care practice has pivoted to telehealth and the physical examination has been ripped away from me, I find myself reflecting on what value the examination has. It is clearly needed at times to make a diagnosis. But I now realise the other ways I use the examination to advance care and its significance to my own well-being. It is a means through which I pause and physically connect with patients, I demonstrate my knowledge and authority, and is a tool I use to persuade patients and re-evaluate their narratives.

Many physicians would say that some diagnoses cannot be made without examining a patient in person. I am not sure how I am supposed to distinguish central vs peripheral vertigo, diagnose otitis media, or determine if someone has orthostatic hypotension without examining a person in front of me. In addition, many of us have cases where an unanticipated finding on examination feels as though it saved a patient’s life. A discovery of an irregular mole, a soft tissue mass, or a new murmur – I do not forget these cases, and I do not think the patients do either.

What was less apparent to me before the pandemic was how a thorough physical examination provides a measure of objectivity that can help me rethink a patient’s narrative. I work in Maine, which has its share of stoics. A patient recently came in feeling a bit tired but felt it was nothing, likely as a result of working too hard. His examination suggested he was in heart failure. If I had not been able to listen to his heart and lungs, and examine his jugular vein and lower extremities, I may have put too much weight on the patient’s lack of concern and missed the diagnosis.

When patients and I disagree on a plan, the physical examination not only provides data, it also acts as an arbiter. For instance, patients sometimes feel a need to use antibiotics to treat a respiratory infection. If I communicate that results of their lung examination are clear and that their oxygen saturation levels are normal, they often feel more reassured that they do not need medication.

The examination, though, is more than a tool that informs diagnosis and treatment. I now realise its value to me. The quiet moments when I am listening to a patient’s heartbeat and breath can be centreing, similar to the part of a meditation where one refocuses on one’s own breathing. Abraham Verghese has commented extensively on the role of the physical examination as ritual and its importance to patients; he also has observed how this ritual brings physicians satisfaction through human connection.3 Only now have I come to recognise the examination as a ritual that is restorative and brings me calmness and confidence.

In an admission of my own insecurity, the physical examination remains one of the few domains where I maintain a sense of professional skill and authority. I have never been much of a proceduralist. The mainstay of what I offer to patients is the ability to listen to them, to use critical thinking skills, and to offer my knowledge and experience. But those skills are sometimes challenged in a world where patients research their own health and develop their own medical narratives. The physical examination remains a place where I offer something of distinct value that is appreciated.

Finally, the physical examination is one of my routines, 15 years in the making, that has been taken away with the emergence of the pandemic. Starting with the principles of active listening, gathering data, and creating a broad differential, I had developed a way of practicing medicine that I felt worked more often than not. While I continued to re-evaluate this process, I did not question each day whether a patient needed a physical examination. But the pandemic has forced me to deconstruct my routine, including the physical examination, in a way that leaves me on uncertain ground. This has been emotionally exhausting and unsettling.

Not all is lost with the emergence of telehealth. At least in these early phases, virtual visits seem to allow me to connect more frequently and easily with patients. With telehealth, I can see patients in their home environments, which often provides me with new information on factors that influence their health behaviours. Virtual visits respect a patient’s time. And, of course, in this pandemic when social distancing is so important, telehealth keeps patients safe. As the months go by, I will adapt and undoubtedly learn new ways to gather physical examination data. Wearable technology or guiding patients through self-examinations will offer some creative approaches to obtain tele-examination findings.

In the past 10 years, with the emergence of the electronic health records and team-based care, we primary care physicians have found ourselves on unsure footing with our identity and way of practicing frequently shifting and disrupted. I have no doubt that when the dust settles from the coronavirus disease 2019 pandemic, things will once again be changed, including a re-examination of the role of the in-office physical examination.

This examination, in its current form, may be left behind. As Michael Rothberg writes, some physical examinations, in our current health care environment, can have unintended costly and risky consequences, leading to “invasive and potentially life-threatening tests.”

While I am sympathetic to this rationale and recognise the benefits of telehealth, I struggle to find equipoise. In attempting to keep patients at a distance, I am losing touch with a part of my professional identity.

 

Doctors, hospitals and mental health providers across the country reported a 50- to 175-fold rise in the number of virtual visits, according to a study released in May by the consulting firm McKinsey & Co.

The COVID-fuelled surge has tapered off as patients venture back to doctors’ offices. But medical professionals and health experts predict that when the pandemic is over, telehealth will still play a much larger role than before.

Studies show patient satisfaction with telehealth is high. And for physicians who previously were sceptical of remote care, necessity has been the mother of invention. “There are still a few doubting Thomases, but now that we’ve run our practices this way for three months, people have learned that it’s pretty useful,” says Dr Joseph Kvedar, president of the American Telemedicine Association and a practicing dermatologist who teaches at Harvard Medical School in Boston.

For patients, the advantages of telemedicine are clear: You typically can get an appointment sooner, in the safety of your own home or workplace, saving time and money on gas and parking – in some cases, even avoiding a loss in wages for missing work.

Telemedicine also provides care for people in rural areas who live far from medical facilities.

Face-to-face visits are generally better for young children. Kids often require vaccinations, and it’s easier for doctors to monitor their growth and development in person, says Dr Dan Vostrejs, a paediatrician at Santa Clara Valley Medical Centre in San Jose.

In general, telemedicine is effective in cases that would typically send you to an urgent care clinic, such as minor injuries or flu-like symptoms, including fever, cough and sore throat.

It is also increasingly used for post-surgical follow-ups. Telemedicine can be a godsend for geriatric or disabled patients with reduced mobility. And it’s a no-brainer for mental health care, which is mostly talking anyway.

Among the top telehealth adopters are medical specialists who treat chronic illnesses such as diabetes, hypertension, cardiovascular disease and asthma, says Dr Peter Alperin, a San Francisco internist and vice president of product at Doximity, a kind of LinkedIn for medical professionals.

Providers can monitor patients’ vitals remotely and discuss lab results, diet, medications and any symptoms in a video chat or a phone conversation. “If you happen to see something that’s awry, you can bring them into your office,” Alperin says, adding it’s “a better form of triage.”

But telemedicine has some serious disadvantages. For one thing, the less formal setting can allow some routine medical practices to slip through the cracks. Perhaps the biggest pitfall in telehealth is the loss of a more intimate and valuable doctor-patient relationship.

 

[link url="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2769550"]JAMA Network report[/link]

 

[link url="https://californiahealthline.org/news/telemedicine-or-in-person-visit-pros-and-cons/"]California Healthline material[/link]

 

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