As Telemedicine Replaces The Physical Exam, What Are Doctors Missing?
Despite a foothold in medicine that predates Hippocrates himself, the traditional physical exam might be on the verge of extinction. The coronavirus crisis has driven more routine medical appointments online, accelerating a trend toward telemedicine that has already been underway.
This worries Dr. Paul Hyman, author of a recently published essay in JAMA Internal Medicine, who reflects on what's lost when physicians see their patients almost exclusively through a screen.
A primary care physician in Maine, Hyman acknowledges he'd already begun second-guessing routine physicals on healthy patients as insurance requirements pushed doctors away from them.
But while Hyman is now providing mostly telemedicine, like many doctors during the pandemic, he writes that he has gained a clearer sense of the value of the age-old practice of examining patients in person. He notes the ability to offer reassurance, be present for his patients and find personal fulfillment as a doctor.
"I think there's something therapeutic about seeing a physician and having them lay their hands on you, and my sense from the feedback I've gotten from the article already is that a lot of people agree that it's therapeutic in its own right — and that can be lost without the physical exam," Hyman told NPR.
Hyman spoke with NPR about his experience adjusting to a new world of medicine, one that eases access to health care providers yet has the potential to erode basic human connection.
This interview has been edited for clarity and length.
How has the sudden shift toward mostly virtual visits changed the way you practice medicine?
It's changing almost week to week as I go through and learn, then try to understand what the virtual visit is providing and what it's not providing. It's kind of a learning experiment in real time. In some ways, I am more cautious because I am not sure what I am missing from not seeing the patient in person. And so I try to think through what I would have gained from the physical exam. And if there is enough of a concern about that, then I will advocate for the patient to be examined.
It does give me, for some patients, a lot of insight into the way they live their lives and what their home or work environment is like, which can help me understand more about where their health concerns fit into their overall priorities. I think it's helped me connect with patients in different ways.
What are some things that are much easier to catch through a physical exam or might be missed using telehealth?
We don't really completely understand sometimes what we're missing because we haven't really done medicine this way. I give the example of a patient whose heart is not working as well, and that's causing fluid buildup in their body. For that specific patient, it would have been challenging to make the diagnosis over the video or a phone; it takes touching the patient, being able to listen to their heart, legs, look at their blood pressure and look at the veins in their neck to make that diagnosis.
Another one that I often worry about is dizziness. People can feel dizzy for many reasons. Some of them are very common and not concerning, but occasionally the reason is serious. It's very hard to distinguish some of those reasons on a video trying to walk a patient through an exam.
Beyond the obvious potential for missing a diagnosis, what else is lost in the doctor-patient relationship when you can't do physical exams?
I have to agree with [Abraham Verghese's] description of a ritual, that there's something about coming into the office and going through a history and being examined — and that ritual provides real comfort and meaning to both a physician and to the patient.
I mentioned in the article, too, that the exam is an objective piece of data. The patient has a narrative of their illness that the physician is trying to understand to help them feel better, but then the patient may think one thing is going on and the physician may think another. The exam can really be helpful as a piece of science or data that helps clarify what should happen next.
Especially in our world of electronic health records and a lot of other things that can be very distracting, it's that moment in time when the physician is fully present. And I think that can be really supportive, meaningful and important.
You mentioned in the essay that one of the primary roles of a physician is listening to the patient. Are there instances where a virtual visit provides a better environment for doing that?
I think there are, if the patient is fully present during the visit. Sometimes patients can be distracted, doing other things. But there are opportunities in the virtual visit to actually really connect and listen without some of the distractions of a busy office and an exam room. We still have to remember that most of what we're going to learn about a patient's illness is going to be through listening to them.
Insurance providers and volume-based metrics have already reduced the frequency of performing routine physical exams on healthy patients. Has the business of medicine already started to devalue a doctor's touch?
I think what is devalued is humanistic interaction between a patient and a physician — development of a relationship and good listening. The way billing codes have worked for primary care, you could put down parts of your physical exam, so it wasn't being completely devalued. But I think it is devaluing to patients to request doctors do visits so quickly. More time is needed, as physicians, to listen to our patients and develop relationships, to think critically about them.
Less time with patients seems to be the enemy for doctors, both virtually and in person.
Yeah, time is the most critical part. And we're just getting less and less of it. I just got an email from a doctor, a pediatric specialist, about how he always does a very complete physical exam because he needs, as we've learned in medical school, to take a step back, think about the big picture and not miss something. That mindset is not valued in the current situation.
You anticipated some wearable technologies that might give more objective information about patients during virtual visits in the future. Are you worried technology may replace the physical exam?
I think there's tremendous benefit to some of the wearable technologies, but I think that society is going to need people to interpret what the wearable technology is telling you. But, we're primary care physicians, we're detectives and we still follow the rules of "when in doubt, examine the patient," right? Right. So a lot of times where I see a patient, when it's not clear what is going on and I'm trying to figure [it] out, I put all these puzzle pieces together.
I think that [the physical exam is] a skill and a tool. I still agree it's a core and fundamental part of being a physician. This isn't, you know, the end to our identity as physicians. I think that we need to evolve. As our data evolves and technology evolves, we need to evolve with it. But we just can't leave it fully behind.
Kristen Kendrick is a board-certified family physician in Washington, D.C., and a health and media fellow at NPR and Georgetown University School of Medicine.
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