|Year : 2020 | Volume
| Issue : 2 | Page : 271-272
Is it an end of the art of “Physical Examination” in the COVID-19 pandemic?
Rajagopal Srinath, T V. S. V. G. K Tilak, Anil S Menon
Department of Internal Medicine, AFMC, Pune, Maharashtra, India
|Date of Submission||27-Nov-2020|
|Date of Decision||21-Dec-2020|
|Date of Acceptance||12-Dec-2020|
|Date of Web Publication||18-Jan-2021|
Dr. Rajagopal Srinath
Department of Internal Medicine, AFMC, Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
The COVID-19 infection has been causing significant burden on the health infrastructure of almost every country and the COVID-related mortalities and morbidities translate into a significant impact on the societal perspective. Adequate precautions are mandatory for the healthcare workers managing patients at healthcare facilities like use of personal protective equipment (PPE) while handling patients. The clinical examination forms an important tool in the evaluation of any patient. For the last few years, the clinical skills of the clinicians have been on the decline noticed by the medical fraternity. The clinicians have become increasingly reliant on investigation reports and imaging technologies to diagnose and manage the patient. The situation of COVID-19 and management of these patients in COVID care hospitals and centers have further diminished the role of clinical skills with the added difficulties of wearing the full component of PPE during the patient evaluation and care. Patients are isolated as per the protocol, and doctors are forced to avail the telemedicine facilities and depend on the objective data provided by the junior doctors or paramedics. The pondering question is, have we reached a new tipping point in the utility of clinical diagnosis, making it further alienated in the future? We will have to wait and see if the clinical skill utility change caused by this pandemic would have a lasting effect.
Keywords: Clinical examination, clinician, COVID, pandemic
|How to cite this article:|
Srinath R, Tilak T V, Menon AS. Is it an end of the art of “Physical Examination” in the COVID-19 pandemic?. J Mar Med Soc 2020;22:271-2
| Perspective|| |
The COVID-19 infection causing severe acute respiratory syndrome (SARS) has been declared a pandemic by the WHO on March 11, 2020. The first cases were reported from the Wuhan province of the Mainland China in December 2019 with cases reaching epidemic proportions in many countries around the world subsequently. The pandemic has been causing a significant burden on the health infrastructure of almost every country in variable proportions including India. The COVID-related mortalities and morbidities translate into a significant impact on the societal perspective. The mode of transmission and the virulence of the SARS-CoV2 organism are such that adequate precautions are mandatory for the health-care workers (HCWs) managing such patients at health-care facilities. These precautions range from the use of personal protective equipment (PPE) while handling patients, proper hand hygiene techniques along with appropriate isolation practices from their family members after working in such facilities. It goes without saying that the safety of the HCWs is equally if not more important than that of the patients and is the most important factor affecting the clinical evaluation methods adopted by the clinician in these changed circumstances.
The clinical examination is an important tool in the evaluation of any patient presenting to any clinic or hospital. The history taking, which precedes the examination includes, apart from the history of the presenting illness, relevant past, medication, and family and personal history of the patient being evaluated. This is followed by general physical examination and systemic examination of the various systems, as relevant to each patient. It is known that clinical examination may have a relatively high sensitivity, but it can have a specificity as low as 15% in certain situations resulting in many positive findings in asymptomatic patients. A few examples are the finding of brisk deep tendon jerks in an apprehensive patient or in cold environment in the absence of involvement of the upper motor neuron abnormality or the presence of physiological flow-related murmurs on auscultation in the absence of valvular heart disease. In addition, clinical examination findings can often be inaccurate, especially at the hands of novices and can have significant interobserver variability. This can be distressing for the patients. While the laboratory tests and imaging modalities can also have variable specificity, they perform better in comparison. However, tests can only corroborate the clinical findings, and hence, we need to rely on clinical findings. Furthermore, tests cannot be seen in isolation and need to be correlated with the clinical findings. The clinical examination is more economical than a battery of tests and proves useful in situations when there are no diagnostic facilities available. More importantly, the benefits of the clinical examination go beyond the diagnostic outcomes in that it serves as a good tool in the building of the patient–doctor trust with clientele satisfaction with the doctor's physical intimacy being the most important factor.
For the last few years, the clinical skills of the clinicians have been on the decline resulting the same being branded as a “dying art” or “lost art” by the medical fraternity. The clinicians have become increasingly reliant on investigation reports and imaging technologies to diagnose and manage the patient. Various reasons have been attributed to the losing or dying art of clinical examination. The foremost being time-bound diagnostic and therapeutic dilemmas with pressure from the bureaucrats or the insurance companies in the corporate setup and the pressure of the volume and number of the clientele in the government or general practice situations. The availability of technology has also resulted in the opportunity to the clinician that can help rapidly reveal the details that are invisible to the naked eye on the routine examination. This growing bane of “Hyposkillia” is very much inherent in the medical fraternity unfortunately more so among the younger generation clinicians across all the specialties. The advances in medical technology have no doubt enhanced our ability to diagnose and manage conditions better. Habitual reliance on sophisticated medical gadgetry for diagnosis always prevents the physicians from using the most sophisticated, intricate machine they will ever and always have, their own brain. Some of the few examples include the reliance on imaging modalities rather than tedious clinical tests by clinicians which not only may be time-consuming but also has an element of subjectivity. There can be multiple situations in almost every clinical specialty where the clinician has an easy and quick investigational modality with the tendency to cut short the arduous and systematic clinical examination in arriving at a diagnosis.
The global pandemic situation of COVID-19 and the management of these patients in specialized COVID care hospitals and centers have further diminished the role of clinical skills with the added difficulties faced by the clinicians of wearing the full component of PPE during the patient evaluation and care. Patients with COVID-19 are isolated as per the protocol, and doctors are forced to avail the telemedicine facilities and depend many times on the objective data provided by the junior doctors or paramedics. As the clinical examination involving contact with the patient is considered a “high risk” exposure, reliance is placed on pressure monitors, Xrays, and computed tomography scans to understand every patient's complete clinical picture. Add to that the difficulty or the unease of the clinician in performing routine palpation, percussion, and auscultation while wearing PPE. The same problem exists in both the outpatient department and inpatient management of the patients. These changes to clinical routines have inadvertently made us even more reliant on technology.
The pondering question is, have we reached a new tipping point in the utility of clinical diagnosis, making it further alienated in the future? We will have to wait and see if the clinical skill utility change caused by the COVID-19 pandemic would have a lasting effect. Will this lead to a new kind of patient care based on gadgets alone, side-lining the clinical examination completely? Or will it bring us back to connect with patients and spur us to deliver the clinical examination more practically and scientifically? What about patient expectations on us, given that telemedicine is more accessible and time-efficient than a traditional hospital visit? It is too soon to tell, but it is unfortunately possible that, thanks in part to the pandemic, the traditional clinical examination may go the way of other outdated medical practices and skills like the now obsolete signs like “Succussion splash,” “Coin test,” just to name a few.
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Conflicts of interest
There are no conflicts of interest.
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