Physicians who are new to telemedicine often fret about the appropriateness – and the limits – of a remote physical. Here are a few lessons we’ve learned at JeffConnect.
Like all new beginnings, telemedicine is greeted with both excitement and caution. It’s exciting that we have yet another avenue of seeing our patients. Yet, we’re cautious in rethinking our own ways of doing histories and examinations as it’s unlike our training and what we assumed to be possible.
A common concern regards our physical examination. How can one perform an examination that is appropriate for patient care? If we can’t, how can telemedicine be a part of our medical practice?
It’s a legitimate question and we get it. We have also seen a lot of patients and can say it’s not nearly as different as you’d first imagine. In no way is this an argument against physical exams. We all know they are more cost effective, give information that cannot be gleaned from invasive testing and are a check on our increasingly low threshold to order a battery of tests. What we do argue against is saying that the lack of ability to perform a “complete” physical examination is a reason to invalidate telemedicine. It’s simply not true for three main reasons: (1) because physical examination is not always reliable; (2) because the great majority of an examination is possible through video with a little creative thinking; and because the alternative to examination via video is often no visit or simply a telephone conversation. The question should not be about whether or not the physical examination is as complete as an in-person visit but whether or not enough of a physical examination can be done to lead to an appropriately actionable decision. Let’s examine both in turn.
First, the assumption that our physical exams are reliable. The implicit assumption regarding the physical examination is that there is a gold standard correct answer. We all know that this is not the case. We can all think of times when we disagreed with a resident or student finding on examination, or times when a specialist or consultant had a different input entirely. Was there one correct answer? No, of course not. In order to be the true “gold standard,” the exam must be both reliable and valid. Let’s take the most basic clinical features used to diagnose a life threatening condition – acute myocardial infarction. Features classically used to evaluate the possibility of AMI, such as pleuritic, positional and sharp chest pain have poor to fair inter-physician reliability (kappa values of 0.27 to 0.44). Think of the last time you heard an S3 or maybe even an S4 – was it obvious to everyone who listened? What about wheezing or rales? Have you ever heard it transiently in a patient? Are you certain about what each and every murmur you think you hear means, if in fact you do hear the same one your colleague said they heard?
The physical exam can, of course, be valuable, but even Osler said 95% of the diagnosis is in the history. He was right. We should listen to our patients. He might have loved telemedicine, where we listen to and observe our patients.
Value of Video PE
Also, we are doing physical examinations. We always do one via video. We simply use our power of observation better. There is a lot of information to be gained looking through the camera at someone (and for our purposes we consider only video visits in this scenario). We can assess skin tone, rate of breathing, gait, clarity of speech. Are they sitting up or lying in bed? Are they pale? Does their breathing look rapid and are they unable to complete full sentences? Or are they walking around in no distress while listing their symptoms. Much of the information from this initial 10 seconds we do as second nature and counts as part of the physical examination.
Patients can also follow our instructions to aid in their own examination – we can have them move their joints, assess if they have pain in specific areas, move the camera to see their eyes, throat, skin rashes, etc. They can take their own pulse while we time them and use their own thermometers to assess for fever. Family members can also be recruited: we’ve used them to examine an abdomen and assess for tenderness under our instructions. We have diagnosed biliary colic and appendicitis in this manner. Not only does this add valuable information to the physical examination, it aids the patient in being an active part of their healthcare. In the above example, having the patient understand where the right lower quadrant is and why it is important to know whether the pain localizes in that region helps them also realize when and why they might need further evaluation.
Yes, without the addition of a device to listen to heart and lungs attached to the patient’s phone, we are unable to perform this examination. How often and how well does the average practitioner hear murmurs, gallops and PMI? As we noted above, our inter-rater reliability is low. Is it really necessary to listen to a patient’s lungs if they have two days of rhinorrhea and a cough, but no fever, shortness of breath or sputum production? We would not treat them with antibiotics for their viral illness. I bet you commonly treat family members over the phone without seeing them. Video visits allow you to see much more – a more comprehensive exam than for your loved ones. For the bulk of the common telemedicine complaints, our management wouldn’t change. Also, our close, uninterrupted online counseling allows the patient to know when it’s appropriate for a higher level of care and what that level is, i.e. urgent care versus the ED. We get the added bonus of seeing the patient in their home environment and understanding what that looks like. You never see that in an office visit.
All of these exam components can be done over video with patient cooperation and provider explanation. While we accept video evaluation has limits, it is not something that should stem the tide of innovation and expanding our interactions with patients. The alternative for many of these patients is either a phone call with a provider or not having any visit. In both these cases, they get no examination. We have to make sure we have the required information for an appropriate evaluation to help treat the patient’s symptoms.. If not, we need and would ask for more help, similar to an office or ED visit. Scrutinizing our basic assumptions and releasing our preconceived blocks about what constitutes care for a patient can aid even more of our population.
TELEMEDICINE PHYSICAL EXAM PEARLS
Common complaints and how to examine them remotely
- Can easily see an eye on video to assess for injection, icterus and symmetry
- Visual acuity with help of eye chart applications which can be downloaded while on the phone
- Instruct patients to move eyes to evaluate extra ocular movements
- Have the patient use a flashlight to evaluate for reactivity
- Finagle the camera to evaluate the tonsils for redness, exudates and swelling
- Ask the patient to evaluate if they have tenderness over their lymph nodes
- Observe if they cough, or have a runny nose, and observe them take their temperature
- These are the same criteria used in an urgent care to screen for strep throat versus a viral sore throat
3. Ankle Pain
- Use the Ottawa Ankle rules
- Ask whether they were bearing weight at time of injury
- Have patient the family or patient palpate over the specific areas of bony tenderness included in the rule
- Evaluate whether they can bear weight
- If it is all negative, you can save most patients a visit to the urgent care or emergency department for an X-ray.
These are only some examples. As with any consult, advising each patient on what is considered an emergent or worrisome progression of symptoms is important. Not everything is appropriate for telemedicine. If you cannot exam something you need to exam, you need to have them be evaluated elsewhere.