Covid forces doctors to end a key ritual – and patients can suffer for it

We are reminded daily of the social ties torn apart by the Covid-19 pandemic. In hospitals, coronavirus patients fight the disease in isolation, receiving care from armored health care workers in personal protective equipment and saying goodbye through phones or iPads. Meanwhile, public health measures, such as blockages, masks and social distancing, have taken away our ability to interact with others.

a person standing in front of a mirror posing for the room

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In medicine, these consequences extend beyond patients affected by coronavirus. As ‘virtual’ medical appointments, which could account for around 20% of all medical visits in 2020, have increasingly moved away from traditional in-person visits, physical examination has become a notable victim. Even for those patients who are still seen in the flesh, the reflexive urge to avoid touching can lead to a shortened or hurried examination.

Due to time constraints with patients and the diagnostic superiority of laboratory tests, procedures and radiographic imaging, many doctors already consider physical examination to be an anachronism. Further underlining the centrality of physical contact in the doctor-patient relationship, the SARS-CoV-2 pandemic continues to threaten the practice. But as the use of examination techniques and medical instruments becomes more functional, doctors throw away a cherished ritual that reduces medical errors and, most importantly, humanizes medicine.

In the late 1700s, an Austrian physician named Leopold Auenbrugger discovered that the pathology of various organs of the human body could be determined by touch. After seeing his father touch the wine barrels to assess their volume, he reproduced the technique with his patients. By touching or percussing organs such as the heart, lungs or liver, Auenbrugger discovered abnormalities such as fluid accumulation or enlargement.

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It became a turning point for medicine because a lot of techniques and tools, such as the stethoscope, the reflex hammer and the blood pressure cuff, appeared following Auenbrugger’s discoveries. And as they have made it increasingly possible to explain human diseases through listening, touching, and inspection, physical examination has become a tool in the physician-patient relationship.

However, in recent decades, the use of diagnostic and laboratory tests has increased. The far-reaching capabilities of laboratory tests, coupled with the time constraints imposed by insurers and bureaucrats, have made physical examination limited at best and superfluous at worst. Radiographic testing, such as MRIs or computed tomography, provides granular information about diseased organs that not even the most competent tactile examination can reproduce. Moreover, despite the ubiquity of the stethoscope in health care, doctors rely much more on echocardiograms and not on the sensitivity of their ears to detect heart murmurs and other structural abnormalities. Perhaps not surprisingly, exam skills have long been in decline.

A 2019 study published in JAMA Internal Medicine found that new interns in interns or interns spent almost 90% of their working time away from patients. Even a small part of the time allocated to face-to-face patients was spent on several tasks (viewing medical records or documenting work).

These findings illustrate how patients are rapidly becoming virtual ‘patients’, identified less by face or touch and more by laboratories, radiographic images and procedure reports. The coronavirus pandemic occurred during this period in medicine. And with that came an unprecedented need for safety for the doctor and the patient.

In addition to patients hospitalized with Covid-19 whose examinations are limited due to isolation and protective equipment, the risk of pre-symptomatic or asymptomatic transmission endangers any space occupied simultaneously by a physician and his patient. To alleviate this threat in the clinic, virtual telehealth has been blessed by insurers and embraced by doctors and patients.

As Dr. Philip Masters, a professor at the University of Pennsylvania School of Medicine, wrote in Kevin®: “It’s as if an invisible“ coronavirus wall ”has risen between us and our patients. And, while it is certainly necessary, the implications of this “virtual barrier to our relationships with patients are neither subtle nor insignificant. “

This is the environment in which medical students and medical residents, who are new to medicine, will now prepare. With the time already reduced in bed before the pandemic, these new pressures can degrade the already full interaction and push the patient further. in the computer.

Although it is tempting to believe that physical examination is an outdated practice that was best suited for the embryonic days of medicine, the data suggest otherwise. For example, take this 2015 study published in the American Journal of Medicine, which looked at 208 cases of physical exam neglect. He found that 63 percent of negligence could have been prevented by physical examination alone. In addition, these shortcomings led to misdiagnosis or delay in 76 percent of cases.

Moreover, a thorough physical inspection of a patient can produce information that only radiographic images cannot. A 2019 study in the journal Hernia found that the presence and accuracy of physical examination information provided to radiologists affects the diagnosis of abdominal wall hernias in up to 25 percent of cases. Crucially, a 2016 study published in Current Oncology concluded that mammograms in the absence of physical examinations of the breasts can miss a significant number of cancers.

For doctors, physical examination must be protected at a time when medical and specialist knowledge is threatened. As Dr. Paul Hyman, a primary care physician in JAMA Internal Medicine, recently noted, “those skills are sometimes challenged in a world where patients research their own health and develop their own medical narratives.”

“Physical examination remains a place where I offer something of distinct value that is appreciated,” he wrote.

But beyond the usefulness of diagnosis for physical examination is the fundamental need for sick and vulnerable patients to be seen, heard and touched by their doctors. Although this “laying on of hands” is a simple act, it remains an important ritual in medicine that communicates empathy, concern and the presence of a doctor. As Dr. Abraham Verghese, a physician at Stanford Medical Center, noted about the desire for sick patients to be examined, “I think there is a deep human need, especially in the context of the disease, to feel that you have that person’s attention. “

From now on, it is not certain how many medical adaptations will be permanent in our post-pandemic world. However, physical examination is an area of ​​medicine that must resist, due to its indispensability for diagnosis and its humanizing effect on the doctor-patient relationship. And until the mass arrival of vaccines allows us to rekindle some of our extinguished human ties, perhaps less attention to the details of patients’ lives when seen virtually, or touching them despite gloved hands, can easily avoid the relationship. simple transactional.

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