key: cord-0800920-05ghmj7k
authors: Mackowiak, Philip A.
title: COVID-19, Telemedicine, and the Demise of the Physician’s Touch
date: 2021-04-01
journal: South Med J
DOI: 10.14423/smj.0000000000001229
sha: 1fa3f8f37fcc3ee067816e290d5936d5c18e10cf
doc_id: 800920
cord_uid: 05ghmj7k

nan

carried an element of risk. With the advent of the coronavirus disease 2019 (COVID-19) pandemic, that risk has intensified as a result of the role of direct contact between individuals in spreading the infection. This is not to say that the danger of becoming infected by touching another person was unrecognized before the COVID-19 pandemic. Infection control practitioners have long extolled the benefits of washing hands between patients, and of isolating those in the hospital with known transmissible infections. Whereas in the distant past comforting patients by sitting on their bed and holding their hand was a part of the art of medicine, recent policies have made the practice an infection control "no-no."

Until now, social distancing was enforced less stringently in the outpatient clinic than in the hospital. COVID-19, of course, radically changed our perception of the health risks of direct contact with outpatients, and for that matter, people in general. As a consequence, social distancing is now as vigorously enforced in the outpatient setting as it is in the hospital. Telemedicinevirtual clinic visits using platforms such as Zoom-has enabled clinicians, for the most part, to do what needs to be done in caring for outpatients without having direct physical contact with them.

In many outpatient practices, telemedicine clinic visits are now the norm. In 2019, for example, the Veterans Administration completed some 2.5 million telehealth encounters, whereas in 2020, such visits are on track to exceed 6 million. 1 Before the pandemic, the Centers for Medicare & Medicaid Services supported 13,000 telehealth visits per week. 2 By May 2020, the number had risen to 1.7 million/week. In view of this rapid, massive increase in telemedicine activity, many practices are considering expanding their telemedicine programs substantially, should reimbursement for such visits continue once the COVID-19 pandemic ends.

The advantages of telemedicine visits are numerous. Aside from their infection control value with regard to the social distancing they provide, telemedicine clinic visits are convenient, cost-effective, and efficient. In fact, many patients prefer them over in-person visits, finding virtual clinic visits easier to attend, while still meeting their medical needs. 3 Unfortunately, many of the most vulnerable patients lack the technology required for telemedicine visits or are uncomfortable with the process. Moreover, although such visits are desirable from an infection control standpoint, the lack of physical contact between physicians and their patients during virtual clinic visits has a number of downsides.

Surveys have shown that the laying on of hands in some manner by the physician is expected by most patients when being seen. 4 Women, in particular, generally report a positive reaction to being touched in a professional situation. This was revealed in a survey (albeit one conducted before the #MeToo movement) in which Fisher and colleagues 5 found that "the affective and evaluative response" to touch by a professional was uniformly positive for women, although more ambivalent for men.

Touch, in fact, has probably always been an important part of physicians' interaction with patients. In the 2nd century CE, Galen, who derived inspiration from the ancient Egyptians through Hippocrates, promoted the importance of the physician's touch in taking the pulse and temperature, and in palpating the body, especially the abdomen. More than a millennium and a half later, Sir William Osler wrote that the "whole of medicine is in observation," not just in terms of what the physician sees and hears, but what he or she feels with the fingers, and, sometimes, smells or tastes, which is not possible during a telemedicine clinic visit. Although instruments to aid vision (eg, ophthalmoscopes) and hearing (eg, stethoscopes) have been developed and can be used by physician assistants to convey clinical information to the physician, no aid for the sense of touch exists.

The physical examination, during which touch plays such an important role, is a unique opportunity to spend meaningful time with the patient, which enhances care in ways that are material as well as intangible. When a physician touches a patient, both parties experience an affirmation of the doctor-patient relationship. The bond established between doctor and patient by physical contact also serves to amplify the information being communicated. When the touch is exploratory, instantaneous, inexpensive results are obtained with a minimum risk to the patient, from which clues to diagnoses are revealed that are of value in directing additional testing, sometimes obviating the need for testing altogether. The physician's touch can be reassuring to the anxious patient. Moreover, a thorough physical examination involving the extensive laying on of hands by physicians instills confidence in patients that their physician is being thorough. Only by touching the patient can the physician (or for that matter a surrogate, such as a physician assistant or nurse practitioner) take the pulse, measure the blood pressure, detect abnormal lymph nodes, ferret out occult mammary tumors, evaluate the abdomen for abnormalities such as a pulsating aneurysm, mass or enlarged liver or spleen, or perform a pelvic, testicular, or neurological examination. None of these can be done during a telemedicine clinic visit.

Such examinations continue to be a cornerstone of the patient evaluation. Most investigations looking into the relative contributions of the history, physical examination, and test results in making diagnoses cite 60% to 80%, 10% to 20%, and 10% to 20%, respectively. 6, 7 Their effects are additive and therefore integrative. In a survey of inadequacies of the physical examination as a cause of medical errors and adverse events published in 2015 by Verghese and colleagues 8 at Stanford University, 208 cases were identified in which failure to perform a proper physical examination or misinterpret the findings of such resulted in missed or delayed diagnoses, incorrect treatment, or other adverse consequences. Ninety-four (45%) of the physical findings missed or misinterpreted involved touching the patient. In a related survey published in 2003, Reilly 7 at the Cook County Hospital in Chicago determined that nearly one in every four inpatients treated at his institution had pivotal findings on physical examination with a potential for substantially affecting their care. In 12 of the 26 cases (46%) cited in the manuscript, the pivotal finding was one detected by touching the patient.

In 1980, at the Tennessee Regional Meeting of the American College of Physicians, Kampmeier, 9 who authored a book on physical diagnosis used by most medical students at that time, mused about what it was like when he was in training. He said, "My generation of medical students did laboratory work which encompassed routine blood counts and sedimentation rate, urinalysis and the PSP test for renal function, the Ewald test meal, Lyon gallbladder drainage and stool examination, and sputum examination for the acid-fast organisms, eosinophils, and Curschmann's spirals."

As a result of the enactment of the Clinical Laboratory Improvement Act of 1988 (Public Law 100-578), student laboratories, where such tests were performed, are now closed. 10 No longer do medical students obtain immediate gratification from diagnoses revealed by tests performed with their own hands. Given the speed with which telemedicine is transforming clinical encounters, one wonders (and worries) whether future physicians in the twilight of their careers will muse, "In my day, we touched patients routinely. It was done during nearly every visit. There was no art of medicine without a physician's touch."

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