We are reminded daily of the social bonds frayed by the Covid-19 pandemic. In hospitals, coronavirus patients struggle with the disease in isolation, receiving care from health care workers armored in personal protective equipment and saying final goodbyes through phones or iPads. Meanwhile, public health measures like lockdowns, masks and social distancing have hollowed out our ability to interact with others.
Even in those patients who are still seen in the flesh, the now reflexive impulse to avoid touch can result in an abridged or hasty exam.
In medicine, these consequences extend beyond the patients afflicted with the coronavirus. As "virtual" doctor appointments, which are likely to account for an estimated 20 percent of total medical visits in 2020, have increasingly pushed traditional in-person visits aside, the physical examination has become a notable casualty. Even for those patients who are still seen in the flesh, the reflexive impulse to avoid touch can result in an abridged or hasty exam.
Because of time constraints with patients and the diagnostic superiority of lab tests, procedures and radiographic imaging, many doctors already consider the physical exam to be an anachronism. By further de-emphasizing the centrality of physical contact in the doctor-patient relationship, the SARS-CoV-2 pandemic further threatens the practice. But as the use of exam techniques and medical tools becomes more perfunctory, physicians are shedding a treasured ritual that reduces medical errors and, most important, humanizes medicine.
In the late 1700s, an Austrian physician named Leopold Auenbrugger found that the pathology of various organs of the human body could be determined by touch. After watching his father tap on wine casks to assess their volume, he reproduced the technique with his patients. By tapping, or percussing, organs like the heart, the lungs or the liver, Auenbrugger discovered abnormalities like fluid accumulation or enlargement.
This became an inflection point for medicine, as a flurry of techniques and tools, like the stethoscope, the reflex hammer and the blood pressure cuff, emerged in the wake of Auenbrugger's findings. And as these made it increasingly possible to explicate human disease through listening, touch and inspection, the physical exam became a fixture in the doctor-patient relationship.
In recent decades, however, the use of diagnostic and laboratory tests has increased. The far-reaching capabilities of lab tests, coupled with the time strictures imposed by insurers and bureaucrats, have rendered the physical examination limited at best and superfluous at worst. Radiographic testing like MRIs or CT scans provides granular information about diseased organs that not even the most proficient tactile exam can replicate. Furthermore, despite the ubiquity of the stethoscope in health care, doctors rely far more on echocardiograms and not the sensitivity of their ears to detect heart murmurs and other structural abnormalities. Perhaps not surprisingly, then, exam skills have long been in decline.
A 2019 study published in JAMA Internal Medicine found that new internal medicine trainees, or interns, spent almost 90 percent of their work time away from patients. Even the small fraction of time allocated to patients face to face was spent multitasking (viewing medical records or documenting work).
These findings illuminate how patients are quickly becoming virtual “iPatients,” identified less by face or touch and more by their labs, radiographic images and procedure reports.
These findings illuminate how patients are quickly becoming virtual "iPatients," identified less by face or touch and more by their labs, radiographic images and procedure reports. The coronavirus pandemic has emerged during this era in medicine. And with it has come an unprecedented need for doctor and patient safety.
Apart from hospitalized Covid-19 patients whose exams are limited because of isolation and protective equipment, the risk for pre-symptomatic or asymptomatic transmission endangers any space simultaneously occupied by a doctor and his or her patient. To mitigate this threat in the clinic, virtual telehealth has been blessed by insurers and embraced by physicians and patients.
As Dr. Philip Masters, a professor at the University of Pennsylvania School of Medicine, wrote in KevinMD: "It's as if an invisible 'coronavirus wall' has been erected between us and our patients. And although certainly necessary, the implications of this 'virtual barrier' on our relationships with patients are neither subtle nor insignificant."
This is the milieu that medical students and medical residents, who are newly initiated into medicine, will now train in. With their time already having been reduced at bedsides before the pandemic, these new pressures may degrade the already fraught interaction and push the patient further into the computer.
Though it's tempting to think that the physical exam is an outdated practice that was best suited for medicine's embryonic days, the data suggest otherwise. For example, take this 2015 study published in the American Journal of Medicine, which looked at 208 cases of oversights in physical exams. It found that 63 percent of oversights could have been prevented merely by performing the physical examination. In addition, these shortcomings led to wrong or delayed diagnoses in 76 percent of cases.
Furthermore, a thorough physical inspection of a patient can yield information that radiographic images alone cannot. A 2019 study in the journal Hernia found that the presence and accuracy of physical exam information provided to radiologists affect the diagnosis of abdominal wall hernias in up to 25 percent of cases. Crucially, a 2016 study published in Current Oncology concluded that mammographies in absence of physical breast examinations can miss a significant number of cancers.
For doctors, the physical examination must be safeguarded at a moment when medical and specialized knowledge is threatened.
For doctors, the physical examination must be safeguarded at a moment when medical and specialized knowledge is threatened. As Dr. Paul Hyman, a primary care physician, recently noted in JAMA Internal Medicine, "those skills are sometimes challenged in a world where patients research their own health and develop their own medical narratives."
"The physical examination remains a place where I offer something of distinct value that is appreciated," he wrote.
But beyond the diagnostic utility for the physical exam is the fundamental need for sick and vulnerable patients to be seen, heard and touched by their doctors. Though this "laying on of hands" is a simple act, it remains an important ritual in medicine that communicates a physician's empathy, concern and presence. As Dr. Abraham Verghese, a physician at Stanford Medical Center, observed about the desire for ailing patients to be examined, "I think there is a profound human need, especially in the context of illness, to get the sense that you have the attention of that person."
As of now, it is uncertain just how many of the adaptations being made in medicine will prove permanent in our post-pandemic world. But the physical examination is a domain of medicine that must endure, because of its indispensability for diagnosis and its humanizing effect on the doctor-patient relationship. And until the mass arrival of vaccines permits us to rekindle some of our extinguished human bonds, perhaps a little more attentiveness to the details of patients' lives when they are seen virtually, or touching them despite gloved hands, may guard against the relationship's becoming purely transactional.