The book Mrs. Leicester’s School by Charles and Mary Lamb depicts a doctor’s visit, illustrated by Winifred Green, 1899Published by J.M. Dent/Getty Images
Jeff Sutherland is a medical doctor and author of Still Life.
In 2009, I went into forced retirement from the practice of family medicine at the age of 43. No, I wasn’t forced out because of professional misconduct. ALS had ravaged my motor neurons over the previous two years, leaving me incapable of raising my stethoscope to a patient’s chest, touching and testing the range of motion of a sore joint or palpating lumps and bumps (to name a few of the physical skills that I no longer possessed). At that time, although my head was full of medical information that would continue to benefit my patients, I was incapable of providing good medical care because I lacked an essential component of making a diagnosis, the physical examination.
In early medical school, we are taught the importance of performing a quality medical examination. This starts with a history of the problem. Like Sherlock Holmes, a physician gathers information by asking questions that start broadly and gradually become more specific as we eliminate the potential diagnoses and form a probable diagnosis. A good clinician will have a firm idea of what is going on with a patient 80 per cent of the time by asking the right questions. One further narrows their diagnosis with a physical examination. This often leads to a definitive diagnosis or narrows down the further tests needed to make a definitive diagnosis.
Since I started my practice in 1993, I have noticed a gradual decline in the quality of physical examinations. I must admit that I had inadequacies in my physical examination techniques. During my training, I could imagine that I saw the jugular venous pressure pulsation that my experienced cardiac preceptor was pointing out at the bedside of a person with acute congestive heart failure. With the advent of skills in bedside emergency echocardiograms, this skill is not as important now. Technology changes the skills required by each generation of physicians, but good physical examination skills will always be an important tool in a physician’s arsenal, that is, until Star Trek’s infamous “tricorders” are invented.
Until then, I feel it is a slippery slope of no return if a physician does not know what a normal and abnormal physical sign is. During the end of my career, while teaching family medicine residents, I found it abhorrent when a resident took the shortcut of auscultating (listening to) breath sounds through a layer of clothes. Unfortunately, we all have heard anecdotes of physicians not asking questions of further inquiry into a patient’s complaints and not doing a relevant physical exam. They were commonplace even before the pandemic. Now with 50 per cent of all patient visits virtual (via phone and video conferencing), skipping the physical exam has become standard practice, and will continue to be in the future.
This was a necessary evil of the pandemic in order to protect the health of patients, physicians and their staff. But as we move through the pandemic, physicians have to be cognizant of what type of visit works best virtually and how often this type of visit should be utilized. I agree that there are some visits that can be done safely and more conveniently virtually, but I would argue that these visits bring more uncertainty into good patient care.
For example, can you see a person’s general appearance – which gives a physician clues about if a patient looks generally unwell or well, distressed or not distressed – through a phone call? As a physician who practiced in the hospital, I would frequently get called at night by nurses who were worried about my patients in hospital. Some of these could be handled over the phone but I had a general rule that if I couldn’t fall back asleep after 15 minutes, I would make my way to the hospital to see the patient. Uncertainty made me go to the hospital in the middle of the night and seeing my patient look overall well or unwell told me what to do next. Video conferencing does allow a physician to gather more information about their patients, but the screen remains a barrier to a physical exam. It also can prevent insights into some personal problems, because a patient’s home is often not private. Would a person who is being abused talk to their physician about this with the risk of being overheard by their abuser?
Uncertainty brings inherent risk for physicians, and more importantly to patient care. The risk for physicians of not seeing patients in person and not being able to conduct a relevant physical examination is missing an important and potentially life-threatening diagnosis. This risk brings the potential of being sued for failing to meet the minimum standards of care. This is mitigated by ordering more tests, which are often unnecessary and costly, or “dumping” patients to the local emergency, which is also often unnecessary and costly. Obviously, this risk of uncertainty to the patients could be catastrophic.
From the perspective of a physician who had to retire from the practice of medicine because I could no longer perform essential physical examinations, I urge physicians to not accept the uncertainty that is inherent in virtual patient care. See more of your patients in person, carefully choose which visits can be done virtually, hone your clinical skills, and rekindle personal connections with your patients. Don’t take away the important tool of physical examination from your tool chest. In my mind, the inability to conduct relevant physical examinations is a disability that prevents a physician from practising complete patient care.
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