The Missing Component of the Virtual Visit
June 15, 2020
David Hoover, MD
The Missing Component of the Virtual Visit
In medical school, an entire first-year class and many parts of clinical rotations were spent learning the art of the physical exam. No one could imagine spending 4 years learning how to care for patients without examining them. We are all taught to use the subjective (what the patient says) and tie it to the objective (physical exam and diagnostics) to formulate an assessment and plan. The physical exam requires touching the patient. Just seeing the patient (not touching) limits the information gleaned from an exam and can negatively impact our ability to accurately diagnose the patient's problem, particularly when physical symptoms are being reported by the patient.
The rapid adoption of telehealth video visits during the COVID-19 pandemic may just be the final nail in the coffin that contains what I and other physicians know as “the art of the physical exam”. The de-emphasis on this time-honored art has been occurring for decades. The physical exam is being compromised by ‘virtual visit’ technology. Yet, technology and art both play a part in the care we offer to patients, they must coexist and evolve together, but the pace of change is now heavily in favor of technology. Art always has a hard time moving fast and therefore suffers.
Reliance on technology is not bad, but the focus on the “shiny new object” can actually threaten the art and have unintended consequences on patient care. Technology rapidly moving ahead of the art is fueled by:
The evolution of imaging and labs: The availability of highly reliable cross-sectional imaging and labs with rapid turnaround times have been a great advancement. For example, we can now see better and more clearly than ever before inside the human body with a 256-slice rapid CT scan or MRI (something the physical exam cannot do). It has become a cornerstone of evaluation in the emergency department yet only a physical exam can tell if the patient has pain or hyperreflexia. The CT scan is hard data and thought to have medical-legal standing therefore it has become the easy way to assess the patient and the physical exam has become less relied upon.
The emergence of the electronic record: The electronic health record has clearly been an advancement with ease of sharing data and decreasing redundant diagnostics. The promised benefit of macro data for disease management has required providers to also become data entry personnel. The provider’s note which used to be a thoughtful story representing the patient’s problem is now a series of checkboxes and dot phrases that have very little meaning. It is common for the physical exam in the electronic record to be pages long and say very little but be assured it will fulfill many billing and population health metrics. Furthermore, EHR's promise of increased efficiency has yet to be realized therefore less time is spent with the patient (resulting in less time for the physical exam) and more algorithms and pathways are created to maximize the number of patients “evaluations” as reimbursement/patient decreases.
The necessity of telehealth visits due to the COVID-19 restrictions: The final threat to the art of the physical exam is the rapid adoption of telehealth/video visits. Healthcare typically changes at a glacial pace due to the complexities of patient care and the enormity of the industry. While behavioral health providers have long used telehealth successfully to overcome shortages/maldistribution of behavioral providers, the rest of the medical community had to rapidly change the process of patient evaluations to video visits alone with the onset of COVID-19 restrictions. Many patients have benefited from telehealth being able to engage the healthcare community from the safety of their homes. Unfortunately, the emphasis has been on technology ensuring our ability to see the patient and none on adapting the art of the physical exam to visual inspections alone. Key elements like accurate vital signs, auscultation of the chest, palpation of the abdomen, and in-depth ear, nose, and throat exams are lost. The provider is working with one hand tied behind their back. This lack of objective data obtained from touching the patient and the new reliance on the visual inspection alone leads to unnecessary studies and therapies being ordered and wrong diagnosis being made. Patients have so far accepted the video visit as an equal substitute for the in-office evaluation unaware that the loss of the physical exam may have unintended consequences. For example, we are now seeing patients present for evaluation to the emergency department in later stages of surgical diseases with a history of a recent video visit that erroneously diagnosed them with a non-surgical problem.
Balancing the Art and Technology
The art of the physical exam is necessary for the practice of medicine and will need to adapt with telehealth. Advances in technology are required for modern medicine and will continue to move fast. We must find a way for the two to coexist, evolve, and complement each other in the times of COVID-19 and beyond. The medical education process needs to address this in how young physicians are trained to minimize the unintended consequences. Furthermore, until adaptations are made, providers will need to have a low threshold to seek specialty help and counsel their patients to come in for an evaluation in person when the clinical diagnosis is not straight forward. Finally, technology must enable rapid specialty consults when there is a question. Whether the patient's need is urgent or can wait, technology must evolve to accommodate provider interaction to ensure the best possible and most timely care of the patient.
To learn how Proficient Health is complimenting the art of the physical exam with technological advancements to help healthcare organizations offer the highest patient care, contact us today!
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