I have been tongue-tied, of late.
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Explore This IssueJuly 2021
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When I was a medical student, I was told not to turn the physical examination into an aerobic workout. This sage piece of advice was imparted by my physical examination preceptor, who had watched me perform a complete examination on a hapless volunteer.
At the time, I thought of the physical examination as a checklist. I moved through the prescribed maneuvers in order, dutifully crossing each off my mental list upon completion.
After watching me have the patient pirouette his way through my ministrations, my preceptor tactfully suggested I consider economy of movement as an important goal. Instead of making the examination convenient for me, I should make the examination convenient for the patient. So, for example, when I had the patient lay down, I should complete all of the maneuvers that required a recumbent position, not just the maneuvers that were next on my list.
To this day, my examination is largely based on the technique I developed decades ago: I start with the patient facing me, which gives the patient an opportunity to become accustomed to me and to my touch. I then have the patient lie down, so I can examine the abdomen and extremities. Afterward, I help the patient sit up and ask if there is anything else I should examine, before I exit to allow the patient to re-robe.
When I became a rheumatology fellow, I added a patter to my examination. Carol M. Ziminski, MD, associate professor of medicine at Johns Hopkins University, is fond of saying, “The hardest thing to do on command is relax.” So while I examine patients, I chat about the weather, about traffic, about anything, really, that might distract patients from the odd intimacy of the moment.
I have performed this song and dance so often I could complete it on autopilot. I engage in mindless banter as my hands move through the examination, virtually on their own, until I feel something beneath my fingertips that requires my full attention.
Back in Business
After a year of conducting clinic visits though FaceTime, my first few clinic visits were shaky. My usual patter was on pause, because I was too busy lurching through the examination, trying to remember what came next.
I was thinking about this as I was working my way through the examination of a patient with isolated mononeuritis multiplex. I knew the diagnosis was correct because the patient had already been seen by two neurologists, including a colleague at my institution who had made the referral largely to avoid having to manage the patient’s immunosuppression.
As I was examining the patient, I explained that isolated mononeuritis multiplex often responds readily to prednisone alone. I was not worried about systemic polyarteritis nodosa because his acute phase reactants had never been elevated, which would be unusual for that diagnosis. He told me his feet were always cold; I told him this was a common complaint among patients with neuropathy. The deadened nerves created the illusion of coolness.
But then I crouched to feel his feet. They were cold. Icy, even. And I couldn’t feel his pulses. I kept digging around until it became unseemly, but I just couldn’t find his dorsalis pedis pulse.
I stood to re-examine his upper extremities, and I realized I couldn’t feel his radial pulse, either. It then occurred to me to ask, “Do you smoke weed?”
He had previously denied using illicit drugs, primarily because he didn’t see why it was important and he didn’t want to be judged, but he had smoked cannabis and tobacco since he was 12 years old.
I asked him to take all the information I had given him about isolated mononeuritis multiplex and put it aside. I then started telling him about cannabis arteritis, an accelerated form of thromboangiitis obliterans (formerly Buerger’s disease) that occurs most commonly in patients who smoke both cannabis and tobacco. Although it has not been reported to cause mononeuritis multiplex, given his absent pulses and lack of signs or symptoms of inflammation, I thought cannabis arteritis might be the best explanation for everything he had experienced.1
He started to slowly shake his head. When I asked him what he was thinking, he replied, “I just can’t believe you could tell all that from taking my pulse.”
Examining the Physical Exam
“Just get on the table and let me take a look.”
I’ve repeated that expression countless times during my career, generally after listening to a patient’s rococo description of their chief complaint. A quick listen with a stethoscope or a tap with a reflex hammer, and I can often reassure the patient they have nothing to worry about.
Because of the pandemic, that simple expression has become foreign to fellows. For a generation of rheumatology trainees, synovitis is the loss of hills-and-valleys between the knuckles rather than the sponginess beneath the fingertips. One of my fellows was beaming because she finally had the opportunity to perform scleroderma skin scores. In March.
When I was a medical student, I was forced to memorize a complete review of systems, called the Atchley Loeb form. Because of this form, my classmates and I learned to ask every patient whether fava beans made them ill, as a method of screening for glucose-6-phosphate dehydrogenase deficiency. When we complained about the length of the form, the course director opined, “Before you can take shortcuts, you need to learn, at least once, how to do it right.”
I have been thinking about this recently while working with trainees in my virtual clinic. As someone who has been doing this for a while, I feel like I might have the advantage, because I have seen the physical exam findings that my patients are now trying to describe to me.
I may be wrong. For example, I recently launched the proverbial million-dollar workup for a long-time patient who didn’t feel right. After I placed over a dozen orders for tests and consults, she elected to go to a local hospital, where she was diagnosed with pulmonary hypertension. I think I would have gotten there, eventually. But if she were in my clinic, I could have heard the accentuated P2.
Another patient had me convinced through the computer screen that his knee pain was due to his granulomatosis with polyangiitis. Fortunately, an orthopedic surgeon got his hands on my patient, literally, and realized he had a severe meniscal tear that was leaving his knee hot and swollen.
Interestingly, few data support a routine physical examination for the worried well. In an evidence-based review of physical exam findings, the U.S. Preventive Service Task Force found support for checking blood pressure, pap smear and body mass index once every few years.2 That’s it.
A 2019 Cochrane review of 15 randomized trials, including over 250 million patients, similarly concluded, “Systematic offers of health checks are unlikely to be beneficial … .”3
If you are otherwise healthy and have no known medical issues, you can safely forgo the routine physical.
You might even be better off—as evidenced by an essay written by an internist whose father underwent a very-important-person evaluation that led to the identification of an incidentaloma, which led to a biopsy, which almost killed him.4 The aforementioned Cochrane report concluded the routine physical examination may actually be harmful for the worried well, because it may result in unnecessary tests and visits that do not lead to benefit. Whoever first said the road to hell is paved with good intentions must have been a physician.
For patients who are worried and less well, however, the physical examination may still play an important role. Verghese et al. conducted a survey of 208 physicians who were asked to submit vignettes in which there was a clinical oversight.5 In 58% of cases, the oversight was due to creating a plan without examining the patient. In an additional 11% of cases, the patient was examined, but the relevant examination finding was misinterpreted. This led to a missed or delayed diagnosis in 76% of the vignettes, treatment delays in 42% of cases and unnecessary tests in 25% of patients.
As a program director, I find it particularly interesting to note that half of these oversights could be attributed to inadequate supervision of a trainee.
Despite my discomfit, no data support the idea that our patients suffer from receiving care through telemedicine. A recent study demonstrated that patients were perfectly capable of reporting their own tender joint count. Studies in orthopedic surgery indicate that an in-person evaluation rarely changed decisions initially made during a telemedicine appointment.
A systematic review of 233 studies of telemedicine in the inpatient, outpatient and emergency settings found:6
- Intensive care unit (ICU) telemedicine consultations reduce ICU and total hospital mortality with no significant increase in hospital length of stay;
- Specialty telemedicine consultations reduce the time patients spend in the emergency department;
- Telemedicine consultations for outpatient care improve access and a range of clinical outcomes.
Another study of a progressive care unit in a large hospital system in Florida found the use of telemedicine led to a 20% reduction in mortality.7
For me, telemedicine has provided a way out of the endless cycle of phone and electronic messages. I used to while away the hours writing carefully constructed missives to patients who sent complex questions through our patient portal. I still do, but now I’m equally likely to set up a telemedicine appointment. I would have felt guilty asking such patients to take a half-day off work to come into the clinic, but I feel no such guilt asking them to turn on their computer.
Piloting the Plane
There is an expression used to describe the innumerable ad hoc solutions we invented during the pandemic: It’s like trying to fly a plane while you’re building it. This expression is particularly apt for describing our transition to telemedicine. Previously, we were told that telemedicine was impossible, because the hurdles were insurmountable. Then, suddenly, we were doing it.
For program directors, the challenges have been even greater; we have had to teach trainees to fly the plane when it was already aloft. Through convergent evolution, many of us have come up with similar solutions. And now a number of resources have appeared to teach trainees how to complete a virtual physical examination.8
The Association of American Medical Colleges has already developed a set of telehealth competencies, and telemedicine curricula already exist in other specialties. This past year, most of us struggled just to get the camera on our laptops to turn on. In the future, rheumatology training programs will need to address the subtleties of telemedicine, such as determining which patients are appropriate for remote visits and how to communicate empathy through the screen.9
These issues are relevant to all of us. I am certain of little in life, but I know this: Telemedicine is here to stay. This year, almost half of all patients have experienced some form of telemedicine, and three-quarters are interested in using telemedicine in the future. McKinsey estimates that $250 billion of healthcare services could be delivered in a virtual environment. This transition would lead to 2–3% cost reductions through improvements in efficiency and management of chronic disease.10
The next hurdle will be cementing all of the pandemic changes that made the transition possible: telehealth payment parity and the ability to see patients across state borders loom high on my list. But we should also not neglect the role of program directors in training fellows for this new reality. Previously foreign concepts, such as webside manner, will become increasingly important additions to our curricula.
I’m also expecting my trainees to train me. Having trained exclusively in a virtual environment, medical students have become adept with certain skills, such as establishing rapport remotely. Growing up with this technology has given them a certain fluency with this technology that I will always lack. I hope the next time we face a pandemic—because who among us is not secretly expecting COVID-28?—my trainees will have trained me to be a better virtual physician.
Or at least not to be so tongue-tied.
Philip Seo, MD, MHS, is an associate professor of medicine at the Johns Hopkins University School of Medicine, Baltimore. He is director of both the Johns Hopkins Vasculitis Center and the Johns Hopkins Rheumatology Fellowship Program.
- Noël B, Ruf I, Panizzon RG. Cannabis arteritis. J Am Acad Dermatol. 2008 May;58(5 Suppl 1):S65–S679.
- Bloomfield HE, Wilt TJ. Evidence brief: Role of the annual comprehensive physical examination in the asymptomatic adult. VA Evidence Synthesis Program Evidence Briefs [internet]. 2011 Oct.
- Krogsbøll LT, Jørgensen KJ, Gøtzsche PC. General health checks for reducing illness and mortality. Cochrane Database Syst Rev. 2019 Jan 31;1(1):CD009009.
- Rothberg MB. The $50,000 physical. JAMA. 2014;311(21):2175–2176.
- Verghese A, Charlton B, Kassirer JP, et al. Inadequacies of physical examination as a cause of medical errors and adverse events: A collection of vignettes. Am J Med. 2015 Dec;128(12):1322-4.e3.
- Totten AM, Hansen RN, Wagner J, et al. Telehealth for acute and chronic care consultations. Comparative effectiveness review no. 216. (Prepared by Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No. 19-EHC012-EF. Rockville, MD: Agency for Healthcare Research and Quality. 2019 Apr 24.
- Armaignac DL, Saxena A, Rubens M, et al. Impact of telemedicine on mortality, length of stay, and cost among patients in progressive care units: Experience from a large healthcare system. Crit Care Med. 2018 May;46(5):728–735.
- How to administer a virtual physical exam: As telehealth visits rise, Stanford physicians offer tips for remote physical exams.
- Lockwood MM, Wallwork RS, Kaitlin Lima K, et al. Telemedicine in adult rheumatology: In practice and in training. Arthritis Care Res (Hoboken). 2021 Feb 8.
- Bestsennyy O, Gilbert G, Harris A, Rost J. Telehealth: A quarter-trillion-dollar post-COVID-19 reality? McKinsey & Co. 2020 May 29.