Why the physical exam is an opportunity we mustn't miss

New health and medical innovations are constantly changing how we provide and receive care. However, we can’t abandon a fundamental part of the care continuum; the routine physical exam.
The Case for the Routine Physical: Capturing a Missed Opportunity

The COVID-19 pandemic has changed a lot of things in our lives. Some are temporary, but others will be permanent. One of the most impactful and probably permanent changes has been how we provide and receive health care. How did the pandemic change the way we seek health care, the way we receive it, and why? What will stay? What will not? Is the future state better, worse, the same? And what does the new evolutionary path for healthcare delivery look like?

These are big questions, and no one knows all (or even most) of the answers. But there is a single, critical component of health care that touches everyone, and has arguably been the most profoundly affected by the pandemic. And although it has been the topic of intense focus recently, it has actually been undergoing a slow-moving shift for many years. It is the patient-clinician encounter, mainly the physical examination (PE).

The most abrupt and obvious change to the PE during the pandemic has been the complete inability to come to a physician’s clinic. Sometimes it was the patient’s desire to avoid exposure to others who might be ill. Other times it was to avoid exposing the office staff to infected patients. Sometimes entire physical facilities were shuttered, or medical staffing was redirected to more urgent care areas such as Emergency Departments or Intensive Care Units. Regardless, the sum effect of this forced separation between patient and clinician was an immediate surge in demand for remote, “telehealth” PE tools. And this had to suffice because, as we all know, at its peak, many health care systems were conducting 100% of PEs using these tools.

Did these telehealth visits include a PE? Certainly not. But before I decry the situation, this tectonic shift did have some benefits. For example, the rapid expansion and dissemination of video chat apps did enable remote and shut-in patients to engage with their healthcare professionals (HCPs) much more easily. New internet-enabled medical devices could capture and transmit vital signs. Expanded local and national reimbursement coverage determinations spurred manufacturers to develop new systems of care that accommodated and improved remote visit capabilities.

But one of the most important learnings has been that the PE, which had been steadily fading from clinical practice and was suddenly, completely forced out of practice during the pandemic, actually is an extremely powerful (and under-appreciated) clinical tool. In fact, by reversing this decline and by boosting the value of the PE, the pandemic will have shown us one of the best ways that we can successfully transition from a clinic-only patient encounter experience to something that can happen anywhere, at any time, and with terrific accuracy and impact. In other words, we have until now let the physical examination become a missed opportunity where we can improve care in many ways. We must not let that continue.

PEs as performed today are rife with errors and the cause of a substantial number of adverse events through missed diagnoses.1 We also know that HCPs on the front line of care miss important pathological physical findings such as heart murmurs.2 This is because, rather than saving the PE by making it better and more effective, we are throwing up our hands and declaring failure. This is misguided, counterproductive, and is having adverse effects.3–5

But first we must look at the state of the art and address the obvious. At present, the “remote PE” is terrible. It is little more than a video chat, and departs completely from the standard of care for a patient encounter. Granted, we had to do something in the face of the pandemic, and we did not have the proper tools at the beginning. For example, if the HCP could only (kind of) look at something like a skin lesion over video, and not take any vital signs or listen to the heart or lungs, that was ok. But we cannot allow that to stand, where every principle of the PE would be lost, where the HCP can only take a history and do little else.

We need to restore the core components of the PE: physical inspection, palpation (feeling), auscultation (listening), percussion (tapping). Without those, how can the HCP tell whether there is a tumor in the abdomen? A new heart murmur? Decreased or absent breath sounds in the left chest? Are we to declare defeat and simply send every patient for a CT scan of the entire body? Besides being simply untenable, such a “non-PE” already makes patients and HCPs feel uncomfortable, inadequate, distrustful, and guilty. Stated in another way, the “video PE” plainly falls well below the standard of care, and puts every patient at risk of missing disease. Yes, we got away with this practice in a time of crisis, but we cannot and should not justify this practice in the long run.

How can we fix this? Should we fix this? The simplest answer is to return to in-person PEs, which will happen to some extent. But not everyone will want to discard the benefits of a remote exam. So we will turn to technology: Developing hardware and software solutions that can replace and recreate the experience of an in-clinic PE and capture the same data as an in-clinic PE. And this approach brings with it a terrific opportunity to build tools that go well beyond the same functionality and performance as our tools of old; they will have more functionality and better performance.

These tools will be used in person as well as remotely. These tools will enable HCPs to perform PEs more quickly, effectively, and accurately, no matter where they or their patients are. These tools will provide value that we have not even thought of yet, pushing disease detection upstream and replacing diagnostic modalities that have up to now been reserved for the laboratory or radiology suite. These tools will have the potential of improving patient outcomes through earlier detection and treatment of disease, as well as reducing the cost of care by reducing the amount of unnecessary, expensive testing.

Not only is this all possible, it is in fact already under way. Examples of these tools include automatic, wireless blood pressure cuffs, weight scales, pulse oximeters; digital, wireless stethoscopes; point-of-care ultrasound probes. More such tools are on the way. Not only will they enable the HCP to conduct an (almost) exact duplicate of the in-person PE, but by collecting and analyzing a much bigger data set than ever collected, will also bring the power of analytics to bear on health care. Changes in a patient’s condition will be tracked and trended; artificial intelligence algorithms will detect disease at least as well as an expert; expensive, inconvenient, and invasive tests will be better utilized and negative studies avoided. The end results are that HCPs will be able to gather the data they need to make clinical decisions, patient and HCP confidence and trust in the results of the PE will grow, and life-threatening diseases will be identified and treated earlier and more effectively.

The sum of this is that we will change the way we practice medicine.

At Eko, we are working hard to move the needle, to save the PE and bring it into the future. Our Eko CORE and DUO digital, artificial intelligence-enabled stethoscopes improve the examiner’s ability to hear body sounds through amplification. The CORE stethoscope can also cancel ambient noise. The DUO stethoscope can add a single-lead ECG. And both of these devices digitize and transmit these signals over Bluetooth to a mobile device or Chrome-based web browser for storage, display, and sharing.

But this is only the beginning of change in what the PE can do. Artificial intelligence machine learning algorithms can now analyze digital signals to detect, among many maladies, heart murmurs and heart rhythm disturbances such as atrial fibrillation. And they can do this at the performance level of an expert, independent of who is actually using the stethoscope, and without variation, fatigue, or unavailability.

By putting this kind of technology into the hands of HCPs everywhere, and enabling them to use it for their in-person and remote PEs, companies like Eko can help bring back the power of the PE and take advantage of the opportunity to detect serious abnormalities as early as possible. We can enable better care, with better outcomes, and capture this missed opportunity.

References:

1. Verghese A, Charlton B, Kassirer JP, Ramsey M, Ioannidis JPA. Inadequacies of Physical Examination as a Cause of Medical Errors and Adverse Events: A Collection of Vignettes. Am J Med. 2015;128(12):1322-1324.e3. doi:10.1016/j.amjmed.2015.06.004

2. Iversen K, Søgaard Teisner A, Dalsgaard M, et al. Effect of teaching and type of stethoscope on cardiac auscultatory performance. Am Heart J. 2006;152(1):85.e1-7. doi:10.1016/j.ahj.2006.04.013

3. Rothberg MB. The $50 000 Physical. JAMA. 2020;323(17):1682-1683. doi:10.1001/jama.2020.2866

4. Stanford Health Care. The Importance of the Physical Exam. Accessed August 6, 2021. https://stanfordhealthcare.org/health-care-professionals/medical-staff/medstaff-update/2016-april/importance-physical-exam.html

5. Hyman P. The Disappearance of the Primary Care Physical Examination—Losing Touch. JAMA Intern Med. 2020;180(11):1417-1418. doi:10.1001/jamainternmed.2020.3546

Sign up for a Demo
A member of our team will respond with one business day.