key: cord-0940356-my532ktm
authors: Erdevir, Mehmet; Uyaroğlu, Oğuz Abdullah; Özdede, Murat; Tanrıöver, Mine Durusu
title: “COVID‐19: The final nail in the coffin for physical examination” Evaluation of the effects of COVID‐19 pandemic on physical examination habits of residents in a university hospital: A cross‐sectional survey
date: 2021-10-26
journal: Int J Clin Pract
DOI: 10.1111/ijcp.14988
sha: 4c28bed36814ca544b0c65b56b1d7dc4cf2ecda0
doc_id: 940356
cord_uid: my532ktm

AIMS: It is evident that the COVID‐19 pandemic has affected the medical practice and training of residents. In this study, we evaluated the physical examination (PE) habits of residents working in a university hospital and how their PE practices did change during the pandemic. METHODS: This single‐centre, non‐interventional, cross‐sectional descriptive study was conducted in a university hospital using an online survey questionnaire between 5 and 20 October 2020. RESULTS: Of the 308 residents who participated in the study, 172 of them (55.8%) were female and the median age was 27 (IQR (3) = Q1 (29)‐Q3 (26)). Amongst all, 263 participants (85.4%) declared that they have worked in the areas where suspected/confirmed COVID‐19 patients were being served. A total of 262 (85%) residents stated that PE habits have changed generally during the pandemic. There was a significant difference with regards to the change in PE habits between those residents who have worked in the COVID‐19 areas (n = 230, 87.5%) and those who have not (n = 32, 71.1%) (P = .004). PE habits of Internal Medicine Residents were changed more than others (P < .001). The main reason for the change in PE habits in general (77.9%) and during the examination of suspected/confirmed COVID‐19 patients (89.7%) were “self‐protection.” Independent factors for limited PE in suspected/confirmed COVID‐19 patients were found as “Avoiding performing physical examination to be exposed less/to protect (adjusted ORs = 13.067),” “relying on laboratory and radiological investigations during practice (adjusted ORs = 4.358),” and “not having a thought that reduced physical examination will render the diagnosis and course of COVID‐19 (adjusted ORs = 2.244).” CONCLUSIONS: This study clearly demonstrated that the COVID‐19 pandemic has had a serious impact on the PE habits of the residents while examining patients in general and with COVID‐19.

General information about the study and an electronic consent • This study has also demonstrated that the residents were actually performing limited physical examination even before the pandemic.

• This study contributes to the literature in terms of drawing attention to "physical examination," which is indispensable in residency training and medical practice.

patients with suspected/confirmed COVID- and in general (Question 11-17) before and after the pandemic were questioned separately for each system (head-neck, respiratory system, cardiovascular system, abdomen, genitourinary, skin/extremity and neurological systems, respectively). Question 18 was "What is/are the main reason/reasons for the change of your physical examination habits in general?" and Q uestion 19 was "Why do you perform limited physical examination in suspected/ confirmed COVID-19 patients?" Question 20 was asked to gather the opinion of the respondent on whether limited physical examination would impair the diagnosis and course of COVID-19.

The study protocol was approved by the Institutional Ethics Board (Approval number: 35853172-900, date: October 27, 2020) and carried out in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki as revised in 2000.

In this study, we utilised an online questionnaire to survey the residents working in the medical and surgical departments. Residents working in the basic science departments such as Anatomy, Biophysics, Biostatistics, Physiology, etc were not included. With the permission of the ethics committee, we obtained the phone numbers of the residents that we plan to approach from different departments and invited them by sending a short letter introducing our study and the link of the survey via message to their mobile phones. A 14-day period was granted to complete the questionnaire.

In descriptive statistics, numbers and percentages were used for categorical variables. For continuous variables with normal distribution, mean and standard deviation (SD) were used; for continuous variables that do not show normal distribution, median and interquartile range (IQR = Q3-Q1) were given. The χ 2 test or Fisher's exact test was used to compare categorical variables. Factors affecting PE in COVID-19 patients or non-COVID patients were analysed using univariate and multivariate logistic regression analyses. Statistical analysis was performed using SPSS 22.0. P values presented at descriptive statistics, comparison studies and logistic regression models were two-sided and were considered statistically significant when below .05.

The questionnaire was sent to 688 residents. Excluding those who did not respond, or did not give their consent, 308 residents participated, bringing the response rate to 44.8%. One hundred and seventy two of these 308 participants (55.8%) were female patients and the median age was 27 (IQR (3) = Q1 (29)-Q3 (26)).

Nearly, half of all the participants in the whole study population and the majority of those who have worked in COVID-19 areas were in the IM group (Table 1) 

A total of 262 (85%) residents stated that their PE habits have changed generally during the COVID-19 pandemic (Table 3) (Table S1 ).

The main reason for the change in PE habits in general (77.9%) and during the examination of suspected/confirmed COVID-19 patients in particular (89.7%) were "self-protection." About 38.2% of participants reported that time spent with the use of PPE is one of the main reasons for the change of their PE habits in general, whilst 48.5% stated that this is one of the main reasons why they perform limited PE in suspected/confirmed COVID-19 patients (Table 3) .

All statements (self-protection, time spent wearing PPE, considering that there are no specific physical findings, reliance on laboratory and radiological investigations and high numbers of patients)

The percentage of participants who ever worked in the COVID-19 areas with regards to residency groups

Each participant was asked to respond to the question of whether he/she was performing a specific course of PE before the pandemic, and whether she/he was still performing it during the pandemic.

A statistically significant difference was observed with regards to changing PE habits in all system-specific examinations except neurological examination in the IM group compared with PED and OTH groups ( Table 4 ).

The OTH group did not seem to change as much as IM did; however, the choice "not performing examination before the pandemic" was higher in all types of system-specific PE except for genitourinary and neurological examinations. The smallest change was observed in the PED group to indicate that they carry on examining their patients persistently in the same way.

The majority of residents in IM and OTH groups performed limited PE in suspected/confirmed COVID-19 patients compared with non-COVID-19 patients. On the other hand, the residents in the PED group was consistently examining suspected/confirmed COVID-19 patients in system-specific PE, which was significantly different compared with those residents in the IM and OTH groups (Table 5 ).

It is evident that the PE habits of all the residents have changed more towards a much-limited examination whilst examining suspected/confirmed COVID-19 patients than in general (Table S2 ).

It was observed that the age and gender of residents were not related to the change in PE habits, both in general and in COVID-19 patients.

On the other hand, working in COVID-19 areas during the pandemic, avoiding performing PE to be exposed less/to protect, thinking that putting on PPE is too much time-consuming, thinking that there are no specific physical findings of COVID-19, not considering that limited PE will affect the diagnosis and course of COVID-19, relying on laboratory and radiological investigations during practice and a large number of patients were factors that seemed to be related to the change in PE habits (Tables S3 and S4 ).

In the multivariate logistic regression model, it is independently predicted that PE is significantly disturbed in IM and OTH groups compared with PED in general and in suspected/confirmed COVID-19 patients. Avoiding performing PE to be exposed less/to protect him/herself strongly predicts change in PE habits that is statistically significant (In general; OR = 7.694, P ≤ .001, in suspected/confirmed COVID-19 patients; OR = 13.067, P ≤ .001) (Table S4) .

practice and not considering that less PE will disrupt the diagnosis and course of COVID-19 were also independent risk factors for performing limited PE in suspected/confirmed COVID-19 patients (Table S4) I avoid performing physical examination to be exposed less/to protect myself This study clearly demonstrated that the COVID-19 pandemic has had a serious impact on the PE habits of the residents whilst not only examining COVID-19 patients but also other patients in general. The main reason for this disruption was "self-protection." Moreover, we have also demonstrated that residents were actually performing limited PE even before the pandemic. The case of residents in the PED group seemed to be an exception, as they seemed to perform a more thorough PE before the pandemic and more consistently carried on doing so.

Examination of the cardiovascular and respiratory system, along with the abdominal area, has been accepted sine qua non of many branches of medicine. In our study, most strikingly, the most significant decline was observed in the IM group, where the residents of this group were supposed to perform these basic examinations in daily practice. This change was not significant in the PED and OTH groups. It was determined that the PED group performed the systemic PE at similar rates consistently before and after the pandemic, whereas the OTH group did not perform systemic PE much before the pandemic and these habits continued after the pandemic as well.

This situation might be explained by the principles set during paediatrics residency, the importance given to the holistic evaluation of the child and the fact that PE is sometimes the only clue as taking the anamnesis can be more difficult in children than the adult patient.

It should also be kept in mind that because of the natural course of COVID-19, children were less likely affected by the disease and there has been no major disruption in the practice of the paediatrics residents, who have worked at a lower frequency in the COVID-19

areas.

Physical examination has become a vanishing art in the last decades. Hyman defined PE as a ritual to physically connect with patients, to demonstrate a physician's knowledge and authority and to be used as a tool to persuade patients and reevaluate their narratives. 5 This ritual is also an experience in which the patient is willingly being examined by his/her doctor and is revealing what (s)he has not explained to anyone else before. 6 Unfortunately, this holy ritual is neglected in the present-day medical practice and is mistakenly thought to be replaceable by a series of laboratory tests and high-tech machines. Evidently, the patient's history and PE are the most important elements in reaching the correct diagnosis.

Laboratory tests and imaging studies often play a complementary role to rule in or rule out the preliminary diagnoses.

In the last decades, grand visits in patients' rooms where patients were examined by professors and juniors all together were replaced by computer-based visits without even seeing the patient that only laboratory and imaging examinations were discussed. Time pressure, an increasing reliance on technology and limited opportunities for bedside teaching have contributed to the demise of the PE. Even before the pandemic, many publications have described a deterioration in PE skills and habits amongst residents and faculty. [7] [8] [9] [10] [11] One of the main regrettable results that emerged in this study was that the rate of residents who said "I wasn't examining before the pandemic" which was significantly evident amongst the other answers. It has been estimated that hospitalists spend <18% and internal medicine interns <12% of their time in direct patient care, but 40% of their time on computer-related tasks. 12, 13 Inadequacy of PE skills of internal medicine residents, especially in the respiratory system and in general, has also been objectively shown before. 14, 15 The selfprotection response during the pandemic period may be justified.

However, the findings of our study are alarming for the future of PE in the post-COVID era and worth discussing. The challenges of the pandemic and the reorganisation of healthcare delivery might lead to a major disruptive change from here on.

Although most medical schools have a structured curriculum to teach PE, training on PE skills is often lacking in residency programmes. 8 We think that this study, by clearly demonstrating the devastating effects of COVID-19 on one of the indispensable skills of physicians, performing a PE, gives an opportunity for improvement in rearranging and adapting the residency training and working milieu with regards to the changing paradigm. Alternative strategies to develop and maintain PE skills of the residents and to improve the safety of the patients should be sought.

Residency training programmes should be re-evaluated in the light of these findings. Otherwise, the COVID-19 will be the final nail in the coffin for physical examination.

The authors declare that they have no financial and non-financial competing interests and they have also no conflict of interest.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available because of privacy or ethical restrictions.

Oğuz Abdullah Uyaroğlu https://orcid. org/0000-0003-0440-2026

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