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May 29, 2020
“You forgot your stethoscope!” The medical student dutifully pointed out as we were on our way to the patient room. “I don’t need it. But let me grab it anyway to pretend. But don’t tell anyone I said that!” I replied. Her eyes widened with disbelief at the blasphemous statement.
At the turn of the millennium, the world was already going through seismic changes in how it conducts itself thanks to the digital revolution. Several age-old occupations were rendered redundant by automation, and new jobs were created due to innovation. Then the pandemic happened. Social distancing stamped the new way of life with a seal of approval. Professions that were considered to be immune to any change, including Medicine, are now facing unprecedented variations in how they are practiced.
One of the first lessons taught in medical school is that the treatment of a patient is dependent on the three pillars of assessment, which include the history taking, physical examination, and the investigations, which include both laboratory and radiographic tests. Since ancient times, medical evaluation entirely consisted of history taking and physical examination. The inventions of the microscope in the sixteenth century and the X-ray in the nineteenth century revolutionized the worlds of investigations, which led to a proportional decline in the utility of the physical exam. History taking stood its ground because even today, it is a widely accepted notion that a good clinician can solve the majority of medical conundrums just by interviewing a patient.
The physical exam consists of four parts. Inspection simply means looking at a certain part or the whole body. Palpation comprises of touching a part of the body with the hands. Percussion is the act of placing a hand or a finger on a part of the body and tapping it with the other hand to assess the underlying area based on the type of sound it makes. This seems to be an archaic practice now. Auscultation is the act of using a stethoscope to listen to the internal sounds of the body.
While the physical exam still remains irreplaceable in emergency situations, it has been replaced by radiography for most of the non-urgent clinical situations. Think of it this way; if you already have an accurate account of the internal organs down to the minute details in the form of an MRI or a CT scan, even the best of physical exams pales in comparison. With a bedside ultrasound, you can see the entire liver or spleen and know the size down to the exact centimeters. The guesswork is gone when it comes to detecting and interpreting heart murmurs since an echo readily shows clear pictures of the heart. As a medical oncologist, I have to routinely assess the size of tumors to know whether they are growing or shrinking, which is accurately done with scans. The neurological exam is most intriguing when a clinician is trying to “localize” the part of the brain that has a lesion, but this practice also seems unnecessary when you have a brain MRI pulled up on your screen.
Of course, this does not hold true for an emergency situation, but these tests are now done so rapidly especially for patients in emergency rooms and intensive care units that it is usually a matter of minutes when you can have a scan done and a trained radiologist giving a detailed report of the internal organs.
Why, then, are we still doing physical exams? There are multiple reasons.
The act of the physical exam is tied in with the identity of a physician. It has been such an indispensable pillar of medical practice that many physicians would consider it sacrilege to call it redundant. A stethoscope is as much the identity of a physician as it is a tool for evaluation. I have had older patients reprimand me for not giving them a thorough check-up if I have done a relatively brief physical exam. There is a certain comfort in the physician’s touch where a patient develops a kindred regard for the physician.
The other major reason why physical exams are still expected to be done is the way medical visits are billed and paid for. The documentation in order to be considered billable, has to comprise of the three major elements, including the history of the illness, the physical exam, and the medical decision making. Physicians now have templates of normal physical exam documentation, which they simply edit to reflect the abnormal exam findings. Sometimes it feels even absurd to perform all the physical exam items. Imagine having a patient who is already tearful and numb after hearing of a new diagnosis of life-limiting pancreatic cancer and despite the availability of scans showing details internal organs, it would be fairly odd at that moment to assess if the trachea is midline or to be asking the patient to perform the finger-to-nose test to assess cerebellar function.
COVID-19 served as one of the final few nails in the coffin of the ubiquity of the physical exam. Medical visits very quickly transformed from “in-person” to “virtual.” This is running very smoothly, and patients are getting most of the medical care that they require. In a small number of situations, when a physical exam has to be done, the patients are asked to come to the office. The patients are finding it very convenient to see their doctor from the comfort of their living rooms and not having to worry about transportation, traffic, parking, or the weather.
Telemedicine has been around for many years now, but it by no means was widely implemented. After COVID-19, it looks like it is here to stay. As this becomes the new norm, all the major elements of the medical evaluation will still stay the same but the previously mandatory physical exam, although still will retain its value under certain circumstances but in a broad sense, will transition from a tenet of medical evaluation to a dispensable and even archaic practice.
This article was published online at KevinMD.com on May 29, 2020
