key: cord-1031686-lmnqtymo
authors: Gelfman, Daniel M.
title: Will the Traditional Physical Examination be Another Casualty of Covid 19?
date: 2020-11-19
journal: Am J Med
DOI: 10.1016/j.amjmed.2020.10.026
sha: 635651fa937c879df39b628f9f8bdde69124a27f
doc_id: 1031686
cord_uid: lmnqtymo

nan

I read with concern a news headline in the September 2020 issue of Cardiology Today entitled, "Telehealth shift during COVID-19 pandemic show capacity to safely deliver cardiology care".

The implication was clear. Other than observation, physical examination is not required for safe patient care anymore. I should say that the article itself doesn't say this. The article does point out that certain visits, such as the discussion of test results and seeing patients in areas difficult to access, can occur virtually. But as this article title implies, and I'm sure many feel, performing a physical examination can be largely eliminated. Even before the pandemic we have all seen practitioners either go through the motions or simply eliminate most of a traditional physical exam in their patient encounters and really only use the patient history, patient observation, and a multitude of ancillary tests in their decision-making process.

With this pandemic, there is not much one can do but go along with a limited or even an observation only physical examination. Clearly, limiting close patient contact with those infected with COVID-19 is important for provider safety. Additionally, when patients are in isolation, it is extremely difficult to do a physical examination. One cannot hear much with the "toy" stethoscope intended for use with isolated patients. And given the frequency of asymptomatic carriers, it is common sense to limit physical close contact and thus limit physical examination with any patient.

After this pandemic is over what will become of the physical exam? It is now becoming acceptable to see and bill patients virtually with no actual patient contact or in person with very limited examination. Students, residents, and fellows now go through their training trying to avoid physical contact with patients. And they watch their attending physicians doing the same.

Performance of, and the skills required to do a good physical examination will be significantly diminished. Trainees simply don't have enough opportunity to learn physical examination skills or how to rely on those findings in their decision-making process. Minimal use of the physical examination will soon become standard practice. This change was already occurring but is now being accelerated. And, it will be here to stay; the numbers of individuals that have the ability to train others in advanced examination techniques will decline as they age.

However, with every predicament there is opportunity. The comprehensive physical examination many of us learned needs to evolve as it takes too much time to learn and perform.

What is needed is to develop a reasonable abbreviated format for examination that combines a sanctioned limited physical examination that is based on recognizing decision points 1 with optional handheld ultrasound to aid in medical diagnoses. Inclusion of bedside ultrasound is not a new idea in patient evaluation. 2 But, the idea of developing an abbreviated combined physical examination with limited ultrasound that can be performed with alacrity is new. The bedside ultrasound should become an optional part of the physical examination, like all the other optional techniques used occasionally during a patient encounter, and not just something that is added on at the end. Frankly, it could replace many of those specialized techniques we were once taught.

It is important to emphasize that ultrasound should not be utilized unless there is a clear reason.

Anyone who reads ultrasound knows that all sorts of confusing findings can be found on This topic is clearly important to the AAIM as evidenced by its position papers as well as multiple articles published this journal, The American Journal of Medicine. 3, 4 Implementation of this change in approach to patient examination doesn't have to be that difficult to accomplish. It has been done before when new technology replaced old. 5 Once the basic format of this new examination is developed, chief residents along with other instructors interested from each Internal Medicine training program could be trained and then become the trainers. As these limited ultrasounds are really just an additional part of the physical exam like the other tools used by physicians, they wouldn't require specific licensing nor billing. Thus, this wouldn't result in expensive licensing examinations or interfere with the official billable ultrasounds. This new physical examination should simply help direct patient care more effectively.

We live in a time of rapid change. The traditional physical examination is rapidly going by the wayside and this is being accelerated with this pandemic. This change presents an opportunity to improve bedside diagnostic effectiveness by changing the physical examination into a time efficient technique that incorporates optional bedside ultrasound. Action now is required to safeguard bedside medical diagnostic accuracy and effectiveness. 

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