The Failing of the Physical Exam

Approximately five months ago, I looked at my office schedule and saw — for the first time — the word “telemedicine” under the names of several patients scheduled to see me after their operations. Little did I know how a single word would change my practice, as well as those of most physicians. After hanging up the hands-free phone on my last post-laparoscopic cholecystectomy telemedicine visit (I had not yet incorporated video assessment), I sat and digested what had just transpired. Within a minute, reality forced me to examine the EMR computer screen in front of me. Quickly, my fingers alternated between percussing the keyboard letters, palpating the computer mouse, and auscultating my pager. After several minutes of Dragon-created verbiage and clicking the appropriate boxes, this postoperative office visit of my patient was complete, though there hadn't been any physical patient to examine.

This is the RVU highway physicians have been forced to travel down. It took a virus to force the federal government and major insurance companies to pay for something they balked at for years: a physician’s time over the phone. I thought to myself, “I think I am going to like this, at least for my postoperative patients.” For full disclosure: as a surgeon, I do not get paid (or generate an RVU) for any office visit after a patient has an operation during a 90-day global period. These have been the rules of the game for surgeons for a very long time. My primary care brethren live and practice by a different RVU business model. I, personally, will not have any use for a first-time virtual office meeting. Call me old-fashioned, but I need to be eye-to-eye with a new patient when I explain to them why an operation is necessary. I also need to visually examine and physically feel where my first cut will be before I commit them to the OR. 

As I write this article, I can hear Leopold Auenbrugger (who developed the art of percussion after watching his father tap wine barrels to determine how full they were) and René Laënnec (the father of the stethoscope) rolling over in their graves. 

Let’s face it, the hallowed art of the physical examination has been on life support for a while now. This is not breaking news. The financial pressures of documenting the physical exam in the EMR has longed sucked all the joy out of performing it. In addition, many physicians today have the luxury of working with APPs to perform the physical exam for them, so its absence in the telemedicine process is not life-altering. 

Unfortunately, the physical exam’s priority in today’s highly specialized practice of medicine was chronically infected with practical neglect well before a simple RNA virus inserted itself into our health care system. This neglect has long been fostered by our easy access to highly accurate technology and heavy reliance on the security of imaging studies to make diagnoses. Many physicians, including myself, have become impatiently insecure with using their inherent skills to arrive at an accurate diagnosis and increasingly more secure in their ability to avoid the legal ramifications of an inaccurate one. 

For instance, many ERs today have imaging protocols in place in order to streamline incoming patients. If you present with abdominal pain, you have a date with the CT scanner well before your dance with an ER physician. “Mrs. Jura, your CT scan shows you have acute appendicitis. I will need to call a surgeon. Now, let me examine your abdomen.” Instead of speed dating, patients are experiencing speed diagnosing. The physical exam has sadly become an afterthought in this complicated era of medical practice. 

Sadly, another nail in the coffin of the physical exam is currently being hammered in by the distracting business pressures placed on employed physicians to produce RVUs, meet their monthly patient numbers, and justify their salary. Somehow, the time necessary for a thorough physical exam gets run over by these pressures and ends up as roadkill to feed the EMR beast. 

The truth is, telemedicine is here to stay. It will play a permanent role in every physician’s practice. As a surgeon trained in the days when asking a question was a sign of weakness, I have embraced this pandemic practice reality. In my surgical practice, telemedicine definitely has its advantages. However, like all newly approved drugs, you truly do not know all the side effects until the drug is exposed to the masses over time. The one short-term concern I have centers around liability. With the virtual physical exam, subtle physical findings heralding the onset of a disease or a cancer will be missed. Then again, they can be missed in real-time physical exams as well. If there is a virtual delay in the diagnosis of a skin cancer, breast cancer, or a missed hernia that later becomes incarcerated, who is liable when the dust settles?

The one long-term concern I have, once the physical exam is laid to rest, is what — or more importantly, who — will be next? Unfortunately, the financial fear inserted into our health care system by a virus may create the foundation for what is to come. Today, hospital systems are looking to become virtually “more efficient,” trying to maintain financial viability by harnessing the money-saving potential of technology. The new motto is: "you can do more with less." With the practical applications of robotic surgery, teleradiology, and artificial intelligence, will the human physician be far behind the physical exam?

Paul Ruggieri is a general surgeon in private practice in Massachusetts and has no conflicts.

Illustration by Jennifer Bogartz

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