HOW MANY HUGS DO YOU GIVE IN A DAY?
“A physical exam is like a hug…you can’t get enough of them.” I’ve mentioned this comment at various settings and it still resonates with me today from when I first heard it. It came not from a medical student, resident, or attending physician but from a patient. As with many issues in health care, this all started with a patient.
A few years ago I was seeing a patient with cellulitis of his left leg. A third year medical student and I went to the bedside to see the patient the student was following. The patient was a pleasant and interactive man and clearly glad to have visitors. While examining him, the student and I also took time to review other areas. The heart, lungs, and abdomen were ours to examine and discuss. The patient was happy to partake and when we were about to leave, he spoke the words above. But will such “hugs” become a thing of the past? The need to turn over patients quickly and the significant uptick in the adoption of telemedicine is pointing in that direction.
The pandemic led our exams to become significantly curtailed and performed superficially at best. Our goal in large part has been to get in and out of a patient’s room as quickly as possible. Even with adequate protection, we have been concerned about our potential for infection, illness, and potentially death. During the pandemic, telemedicine took on added meaning for patients and physicians. Here was a way to safely talk with and examine patients and come to a conclusion about a differential diagnosis and plan. The use of laptops and cellphones became commonplace in our patient interactions and they have persisted. These tools have enabled us to do our work quickly and efficiently. And for many, telemedicine has been a lifeline that many have embraced. For patients in areas lacking primary care physicians and specialists, suffering with disabilities, or having travel concerns, telemedicine has truly been lifesaving. During the height of the pandemic, it was not uncommon to see many ‘how to’ videos of patients with dermatologic and orthopedic issues and how to examine them. The patient became an active player and director of the scene, controlling lighting and phone angles. Patients were satisfied as they could “see a doctor,” didn’t have to travel, and could be in the comfort of their dwelling or other location with nothing more than a laptop, computer, or cellphone….with camera attached. However, those lacking such devices or knowhow did not fare as well. These folks were often left in the dark. But things significantly improved over time and, hopefully, with the $110 million from the American Rescue Plan Act, Delaware’s commitment to broadband expansion will help solve the access problem for many1.
While telemedicine is generally faring well, the pandemic, however, has pushed the history and physical examination further by the wayside. This key component of medicine has been in trouble for some time. What we are now seeing even more plainly is a lack of a skillset that has provided physicians and patients with that special relationship instilled in what we do. Over time, there has been a lack of the development of observational skills, and in many ways dissolution of the doctor/patient relationship. Why take a detailed history and perform a physical exam when you can order an ultrasound, CT, or MRI and get much more information than you could ever want? Does it matter if you don’t have a personal connection with your physician? For some patients, the relationship can be lifesaving, and time at the bedside in a hospital or outpatient exam room can serve a valuable purpose. This may be especially the case for younger individuals who, as a group, are exhibiting a high prevalence of anxiety, depression, and suicide2-5. And for many, a doctor’s appointment holds hope, confidence, empathy, caring, and so much more for patients that lack many of these things. Realizing so many are lonely in our society and lacking some or any supports is sobering indeed. And for so many, just realizing their heart, lungs, and abdomen sound and feel good is very important. If nothing else, a doctor’s visit is something many look forward to, serving as a ray of light in days that may indeed be rather dark and lonely.
While many are armed with smart phones, the interaction is not the same as an in-person visit. Nuances of a patient visit requiring observations such as tone of voice or exam subtleties may not be well appreciated by way of a device. Many things are hard to diagnose and treat without being on site, on location with a doctor. This is especially true for obstetrician/gynecologists, dermatologists, surgeons, orthopedists, primary care physicians, and others. For hospitalized patients with systems pressing to have patients moved in and out quickly and discharged during an early part of the day, the role of the history and exam has also been diminished. The same holds for outpatients of primary care and specialists alike with the need to streamline visits and see large numbers of patients. With patients being admitted more ill than ever before, time spent at the bedside getting to really know our patients is becoming a thing of the past.
Appearing in the Journal of Hospital Medicine, September 20216-8 was a point/counterpoint regarding the routine daily physical exam in the hospitalized patient. The discussion for one viewpoint centered on the physical exam as being “at best a waste of time, and at worst potentially harmful.” The counterpoint argument to the physical exam is threefold. The first is that it provides practice to develop diagnostic finesse. Next, inadequate, or incomplete exams may lead to errors or adverse outcomes10-11. Finally, the belief that the ritual of the physical exam strengthens the doctor-patient relationship. And while being at opposite ends of the spectrum, both viewpoints noted the exam needs to be better than what is usually performed. And to add another piece to this discussion, as of January 2021, outpatient Medicare reimbursement no longer requires physicians to use a physical exam to determine the appropriate level of evaluation and management coding9. Who would have thought Medicine in the 21st century would have led to a controversy about what physicians do or don’t do at the bedside!
Where do we go from here? Without adequate attention to our patients both by listening, observing, and examining, doctors in training and those who will be coming up the ranks will lose something vitally important. The power of the doctor/patient relationship and the power of observation and touch may be lost in a world of advanced technology. The ongoing distancing that is already occurring between doctor and patient will continue and become more of the accepted norm. That is not to say we should abandon technology and spend most of our waking moments in patients’ rooms. Clearly, newer technologies have been useful adjuncts in our armamentaria. Witness the development of point of care ultrasound to verify an exam finding or the use of artificial intelligence to assist with the diagnosis of diabetic retinopathy and more13-16. Yet as the lack of physicians in the U.S. increases for a variety of reasons and those choosing primary care as a specialty struggles to keep up with demand, a relationship with a physician is destined to be lost. Many doctors and patients will continue to hold tightly to their smart phone, laptop, and computer and stare into a cold, dark screen - no “hug” in sight.
Matthew J. Burday, DO
- Delaware invests $110M of fed funds in broadband access - Delaware Business Times
- The Mystifying Rise of Child Suicide | The New Yorker
- Mental Health, Suicidality, and Connectedness Among High School Students During the COVID-19 Pandemic — Adolescent Behaviors and Experiences Survey, United States, January–June 2021 | MMWR (cdc.gov)
- New CDC data illuminate youth mental health threats during the COVID-19 pandemic | CDC Online Newsroom | CDC
- Mental Health | Adolescent and School Health | CDC
- Journal of Hospital Medicine: Vol 16, No 9 (wiley.com)
- Point: Routine Daily Physical Exams in Hospitalized Patients Are a Waste of Time - Rodman - 2021 - Journal of Hospital Medicine - Wiley Online Library
- Counterpoint: Routine Daily Physical Exams Add Value for the Hospitalist and Patient - McNamara - 2021 - Journal of Hospital Medicine - Wiley Online Library
- Big changes made to E/M codes in 2021 | ACP Internist
- The decline of clinical skills: a challenge for medical schools - PMC (nih.gov)
- CMPA - What happened to the physical exam? (cmpa-acpm.ca)
- Culture Shock — Patient as Icon, Icon as Patient | NEJM
- Pandemic spurs paradigm shift in artificial intelligence (healio.com)
Schmidt-Erfurth U, et al. Ophthalmology. 2020;doi:10.1016/j.ophtha.2020.03.010.
- Milea D, et al. N Engl J Med. 2020;doi:10.1056/NEJMoa1917130.
- Lessons Learned About Autonomous AI: Finding a Safe, Efficacious, and Ethical Path Through the Development Process - American Journal of Ophthalmology (ajo.com)