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THE therapeutic benefits of a “hands-on” physical examination may be missing in video consultations, but partnering with your patient to optimise conditions, preparing properly, and listening closely can still elicit good diagnostic decisions and that all important doctor–patient connection.
“A physical examination is a ritual,” Dr Maja Artandi, a Clinical Associate Professor at Stanford University, told InSight+ in an exclusive podcast.
“We all know the physical exam is an important diagnostic tool but its other important function is to make the patient–provider connection.
“When patients are sick they expect to be examined, they expect the provider to lay hands on them, and if that exam is done well, with skill and knowledge and respect, it actually has a therapeutic effect.”
“Guidelines and consensus on how to perform a telemedicine physical examination do not yet exist,” wrote Dr Artandi and her colleague, Dr Stephen Russell from the University of Alabama, in the MJA.
“Without the appropriate training and guidelines, the rapid transition to telemedicine risks lowering the quality of diagnostic care during a medical visit. Currently, there is very limited high quality evidence showing that virtual care, especially when a physical examination is needed, does not increase the danger of misdiagnosis or of ordering costly tests or unnecessary prescriptions.”
So, how are either diagnosis or connection possible at a distance, via video?
According to Russell and Artandi, the answer is yes, under the right conditions.
“We want a strong internet connection,” Dr Russell told InSight+. “We’d like to have a well-lit room that gives an opportunity for the physician to be able to observe the patient and some of the subtle findings that may be present.
“We want there to be a good clear goal of the visit as well. When patients come in with a very specific or directed concern, it does make it a little bit easier for the physician to be able to perform their exam.”
In 2020, Stanford University researchers devised the “Presence 5” – five validated techniques “proven to enhance connection and communication between [health care] providers and patients”. When telehealth boomed following the outset of the COVID-19 pandemic, the same researchers adapted the techniques to telemedicine, dubbing them the “Telepresence 5”.
“The Presence 5 includes preparing with intention – read the patient’s notes before meeting the patient, and don’t take the previous patient’s problems with you,” said Dr Artandi.
“Listen intently and completely; don’t interrupt the patient, give them the chance to say what they want to say. Then you can ask questions – agree on what matters most. Connect with your patient’s story – celebrate successes, for example.
“The last one is explore emotional cues and name those cues. Studies have shown, even if you get it wrong, the patient still really appreciates that you try to name it.”
The Telepresence 5 is similar but has two important adaptations for online consultations.
“While they’re similar, there are a couple of key points to emphasise,” Dr Russell told InSight+.
“Preparing with intention – it does help to have a desktop screen that’s open to make sure that you’re at the right patient’s chart. Of course, we know that when we’re sitting across the room from someone, but it can be easy to overlook that when you’re doing a telemedicine exam.
“It’s easy to be distracted. When we’re on our computer, we’re accustomed to multitasking, be it looking at email or checking something on the internet or looking for great sales. It’s really important in the telemedicine space to block out things that might distract you and be able to look specifically at your patient, which also factors into the connecting with your patient’s story.
“If we find ourselves looking at the camera, we’re much more likely to be seen as making eye contact with our patient.”
Objective data collected by the patient using home monitoring devices such as pulse oximeters, blood pressure cuffs and blood sugar monitors, either before or during the exam, are useful, as is simple observation.
“One of the very first things we do in a face-to-face clinical encounter is to assess vital signs,” said Dr Russell. “How fast is the patient breathing, can they tell their story without having to take a breath? Some of those same ideas can be implemented at the beginning of the telemedicine exam.”
Dr Artandi said the patient’s environment also tells a story.
“Are they laying in bed? Or are they in their car, or at work?” she said.
“You can also learn a lot about the patient by where they are. The patient suddenly is not Mrs Smith with diabetes in room five, but it’s Mrs Smith, who shows me her lovely garden or her pet lying at her feet.
“It’s a very different connection.”
The all-important physical examination is where that connection with the patient comes to the fore.
“The diagnostic yield of the telemedicine encounter improves when physicians partner with the patient in performing the physical examination,” Russell and Artandi wrote in the MJA.
“Known as the ‘provider-directed patient self-examination’, this approach has the provider explain (and even demonstrate) the manoeuvres, coaching the patient through the performance of the examination. Upon doing so, the patient can then report physical findings.”
Dr Artandi said there was an element of fun in teaching and demonstrating exam techniques.
“It’s actually fun for the patient to do their own exam if you explain why you’re doing that,” she said.
“If I have someone coming in with a sore throat, for example, and I want to figure out if they have strep, I explained to them how to feel their own lymph nodes. I demonstrate in front of the monitor, and ask them if the feel anything that feels like a marble.
“I have them get a flashlight, open their mouth and see if I can see the tonsils. And if I can’t, I have them go to a mirror and look at the back of their throat. If it’s white, if there’s pus, let me know.
“It’s surprising what you can do.
“When I started, I was like, there’s absolutely no way I can do a shoulder exam or a knee exam or back exam on telemedicine. But when I demonstrate all the movements to the patient, and I have them palpate their own areas where it hurts, it works really well.”
“It’s also an opportunity to balance out what may be a power differential or a power dynamic,” said Dr Russell.
“Many times, in a face-to-face examination, the patient may be deferring to the physician, because of what is deemed a knowledge base that the patient is coming to be able to receive.
“But it’s an opportunity to actually partner with your patients, and do a joint activity together, where each person contributes a key portion of the exam, to be able to communicate to the other person what’s going on.”
Of course, inevitably, there are situations where a telehealth consultation is not appropriate.
“Making sure that the patient is safe, that’s important,” said Dr Artandi.
“We need to have a good environment. If it’s dark, or if it’s loud and I can’t hear or see the patient, that doesn’t give me good information.
“There are things that cannot be done on a telemedicine exam – if someone comes in with ear pain, for example. We still cannot evaluate the inner ear or the middle ear with telemedicine.
“Patients who are acutely ill, like chest pain, acute, severe shortness of breath, should never schedule a telemedicine exam. They need to be evaluated in person.”
Russell and Artandi told InSight+ they believed examination via telehealth was “here to stay” and should be taught in medical school.
“We expect the future generations of doctors to be good at this, so we need to teach it.
“If students learn to integrate telemedicine into their examinations, from the earliest days of learning the examination, it’s going to be more helpful for them, not only to understand what’s effective in a telemedicine space but it also may open up some opportunities for research.”
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As an experienced Emergency Physician [40 years] having assessed and examined thousands of patients of all ages with an extensive range of conditions a thorough physical [hands on] examination is essential, it may be OK for a GP with patients who do not have a serious condition to make a diagnosis without a physical examination but not in many other environments including emergency departments.
The context of the video “examination”, seriousness of the patient’s condition, ability to communicate, need for vital signs etc defines the suitability and safety of video examination/diagnosis
Great article on patient centred care. It is worth noting that the majority of Australian GPs have decided, me included, that a telephone consultation is the optimal first line for telehealth, in the environment that we operate in. All of the points above are also relevant there and medical training should also focus on skills with this channel of service delivery
Those researching patient outcomes might include this in their study questions.
I am working currently in a remote setting with limited access to internet and phone data services
“Anonymous” asserts that “It is impossible to have a proper 3D appreciation of what you see on the computer screen. ” This makes no sense. Anonymous is confusing a screen image with a static image, such as a photograph. The only thing required to convert a screen image into 3D is to ask the person to move around, or rotate the body part – and – voila! – a 3D view. It’s really not that hard. And, if the provider is still unsure, you refer or create a safetynet plan.
One wonders whether the need to felt by some to comment anonymously reflects an uncertainty about their assertion.
I have been working in Emergency Telemedicine since 2018, after 35 years in hospital Emergency Medicine. This article resonates with me, as I have fine-tuned by ability to assess patients with voice, functional status and various other manoeuvres. If I am not confident in my assessment, I set up a safety net or refer for review immediately. I don’t think anyone is claiming that telemedicine should replace face-to-face, but it can certainly supplement, and definitely increases access.
Over a long career I’ve seen patients “misdiagnosed and mismanaged” (as someone anonymously asserts) in a small minority of cases from all types of practice settings – other EDs, GPs, community specialists, other hospitals, my own hospital – from face-to-face consultations.
More diagnoses are missed by not asking and not thinking – particularly not considering the pathophysiology.
I recently asked an elderly lady with a very sore shoulder to try raising her arm. I was able to see her but did not need to touch her to see that she used the other arm to hold and raise it while cringing, but was able to hold it above her head without pain. Diagnosis? Painful arc syndrome, supraspinatus tendon pathology (remember that anatomy?). Another provider had seen her face to face, done no examination but ordered an ultrasound. Same diagnosis, but delayed by a week, as was the required physiotherapy.
Other examples: a lady with COVID is concerned that her pulse oximetry is fluctuating widely over short periods, without any change in activity. Is it the machine or is she really hypoxic? How can I check that the machine is sensing her pulse properly over the phone? I get her to watch the flashing light on the oximeter and check whether it matches her pulse at the wrist. It does. What is the reading? 99%. Problem solved, patient safety-netted but saved a long wait in ED.
So, both anonymous people seem to be under a misapprehension. Telehealth examination can include anything from asking a child over the phone to jump up and down on the spot, or asking a parent to describe their baby’s chest while they breathe, down to watching a child at home on video interacting with their siblings, unafraid of the provider or a strange clinical environment.
Telemedicine is certainly not “destroying the profession” – it is adding greater choice and access. If anything is destroying the profession, it is substituting a test for a thoughtful clinical assessment using intelligent knowledge of anatomy and pathophysiology, and an explanation to the patient and family.
More than 100 years ago Sir William Osler famously said ( and it was drummed into us as students in the 1960s ) “if you don’t know the diagnosis after a thorough history, you will little wiser after the examination.” This remains true in most situations, and underlines the premise that if telemedicine is going to be effective it will require detailed, accurate and focused clinical histories. Perhaps in this age of diagnosis by multiple scans rather than history and examination, the art of accurate history taking will be resurrected.
Please do not let this become the new standard of care. I’ve seen so many patients end up at Emergency departments because they’ve been misdiagnosed and mismanaged by this crazy new era of so called Telehealth.
I can understand it being useful in rural / remote locations or for patients who are too immobile to attend clinics, but otherwise it is a scam for lazy doctors getting paid to sit at home in a comfy chair doing very little !
It is impossible to have a proper 3D appreciation of what you see on the computer screen. The telehealth is an absolute monkey business which is the way that a lot of doctors love to make high revenues for their minimally involved work. It destroys the profession.