Did Covid and Telemedicine Finally Make the Physical Exam Obsolete?

Left to my own devices, I would be selective about when and how much of a physical exam I do: either not at all or very detailed for just those things that can help me make the diagnosis. I have no patience for boilerplate normal exams. Any doctor who uses the term PERRLA (pupils equal, round, reactive to light and accommodation) is probably faking it. First, most of the time this isn’t actually tested completely and, second, even if it’s done correctly, it has no relevance in the majority of chart notes I have found it in. I have actually seen it in office note templates for urinary tract infections!

It is well known that the history makes the diagnosis in the vast majority of cases. But that task – or art, actually – is sometimes relegated to support staff or forced into unnatural click boxes. Because reimbursement until very recently was tied to how many items were asked about and examined, there was a loss of the story, or narrative, of the patient’s illness. And you could get more brownie points by including things that were extremely peripheral to the clinical problem at hand.

EMRs make it easy to produce long office notes with lots of reimbursement and quality scoring points of uncertain clinical value and accuracy.

Specifically, the physical exam has in many instances become a corrupted, fraudulent, one-click travesty of the art and professionalism we swore an oath to hold high when we graduated from medical school.

The pandemic and the rush toward telemedicine made it clear to most people that medical diagnosis, advice and treatment is entirely possible without physical contact. It was just a matter of getting paid for it, or the healthcare industry would have come to a stop, or at least a crawl.

Now that we have admitted that listening, talking and a certain amount of looking or observing can be done without being in the same room, it is time for us to be honest about the value of the physical exam:

    It is a ritual.
    It is often irrelevant.
    It is often done poorly.
    It was exploited for reimbursement when cognitive work was undervalued.

Our medical education in universities and tertiary medical centers taught us how to handle complex and baffling cases that had eluded diagnosis in the primary care setting: Start from scratch, assume nothing. This is a method we need to use in select clinical situations.

But in everyday practice that is inefficient and unnecessary. Most of what we see is simple stuff and part of our job is to triage, to know when something seemingly ordinary is or has the potential to be more serious.

We need to know how to do a really good and relevant physical exam when the situation requires it. But we also need to know when that would add nothing and only waste our time and effort.

(“Routine physical exams for asymptomatic people are a separate topic. They have almost no proven value according to Choosing Wisely. Even clinical breast exams are not supported by evidence.)

Let’s embrace the new honesty about the value of our work:

Our work cannot always be measured by its comprehensiveness or by the time it takes. The sages people have sought out throughout human history all tended to be brief and to the point, which is part of why they have always been valued. They see the central issue more clearly. So should we as physicians. We need to know where to spend our effort.

The practice of medicine is cognitive work. The more skilled you are, the less you may need to fumble around to make a diagnosis. The better you explain and motivate, the less time you might need to initiate a treatment plan for each patient.

Televisits tended to take less time than in-person visits. Consider the implications of that in this era of purported physician shortages. It is part of the basic question: Where is our training and experience best used, performing ritualistic and pseudo-comprehensive exams or zeroing in where attention is needed?

I am not advocating telemedicine over in-person visits. Telemedicine can be convenient and practical, especially when you live hundreds of miles from specialists. But I am advocating a different view of the clinic visit in general:

Stop faking comprehensiveness. Have the courage and integrity to do only what the clinical situation requires. Don’t fill your visit or office notes with phony fluff. If you then have time left over, use it to relate to your patient as a human being, instead of a virtual/human checklist.

8 Responses to “Did Covid and Telemedicine Finally Make the Physical Exam Obsolete?”

  1. 1 Lisa Scheid RAmey, MD June 11, 2021 at 6:38 am

    Brilliant! Thanks for sharing your wisdom! Also, we know each other from senior year in Kingston. Honored to know you! I loved being a country doc in NH

  2. 3 Henry Hochberg June 11, 2021 at 12:41 pm

    WNL = We Never Looked

  3. 4 Thomas J. Locke III MD June 20, 2021 at 8:42 am

    The unspoken premise in this line of reasoning reflects the painful reality that those who were raised on EMR’s- who checked boxes to generate reimbursement- never learned to perform physical diagnosis. We have more than a generation of doctors and even more noctors, who don’t know HOW to do a physical exam. If you are able to perform an exam it is not dishonest to state that you have done so. The pandemic provided clinicians with the excuse not to touch people. But incompetency in physical examination predates the pandemic. There are still a precious few of us with gray hair who were around before there were EHR’s and before the bean counters were in charge who actually learned how to do a physical exam. Hopefully we will have opportunities to pass on these skills to those who don’t believe they exist before we leave the profession. Physical diagnosis is still a useful tool but like any tool you have to know how to use it. Physicians need to be as proficient at using their hands, eyes, ears AND BRAIN as they are using a mouse and a key board.

  4. 5 Traci Grossman, MD June 20, 2021 at 6:52 pm

    I think we were separated at birth!
    Exactly what I say to whomever will listen. But, mostly to my dog because he will ALWAYS listen. I believe we have moved from the art of medicine to the practice of “mudicine”. We slog through clicks and templates and mandatory garbage which muddies what we should really be looking for, or actually, listening for. Thanks for a great piece.

  5. 7 Thomas Locke June 21, 2021 at 12:41 pm

    Interesting. I vent to my chocolate lab as well. I hope we can educate clinicians in the ART of physical diagnosis- before our time on the planet is over

  6. 8 drpattersonmd June 26, 2021 at 11:42 am

    Couldn’t agree more about the lack of utility of comprehensive physical exams in asymptomatic patients. Hopefully, with documentation changes required by CMS implemented in January 2021, the incentive to check ‘bullets’ in templates will reduce. The human touch element is still an important therapy for patients who expect that from physicians, thus the exam still has some merit and importance. Great entry!

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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