Approach to the telemedicine physical examination: partnering with patients

Medical providers who learn physical examination techniques early in medical training can spend years honing the craft of observation, palpation and auscultation. When performed knowledgeably and well, the physical examination offers clues for diagnosis. It also offers connections with patients. Both doctors and patients benefit from this hands‐on ritual of examination.1 The coronavirus disease 2019 (COVID‐19) pandemic, however, has threatened this connection.

To keep patients and providers safe from a potential exposure to severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), a rapid shift occurred in many countries from in‐person visits to telemedicine visits. At its peak in April 2020, telemedicine was responsible for 36% (5.8 million of 16.2 million) of all ambulatory visits among beneficiaries of Australia’s Medicare program. Even though this number has decreased, the number of telemedicine visits in Australia among Medicare beneficiaries is still substantial, with about 20% (3.4 million out of 17.3 million) in June 2021.2

Many excellent guidelines exist on the logistics of performing a virtual visit, reviewing the use of appropriate technology, the protection of patient privacy, and the suitability of determining appropriate patients for a telehealth visit.3 When physicians shifted from performing in‐office visits to virtual medical care, providers began examining patients remotely without formal training or clear understanding of telemedicine examinations. However, guidelines and consensus on how to perform a telemedicine physical examination do not yet exist.

Without the appropriate training and guidelines, the rapid transition to telemedicine risks lowering the quality of diagnostic care during a medical visit.

Currently, there is very limited high quality evidence showing that virtual care, especially when a physical examination is needed, does not increase the danger of misdiagnosis or of ordering costly tests or unnecessary prescriptions.4 There are some data showing an increase in antibiotic prescriptions for infants presenting with ear pain when they have a telemedicine visit.5 More research is needed to evaluate the performance of a telemedicine visit on outcomes and quality of care.6

As with any physical examination, physicians are more likely to identify and interpret abnormal findings in an optimal setting. For telemedicine, optimal environments include stable internet connections for both provider and patient, well lit rooms, reduction of ambient noise, and appropriate privacy for a physical examination and sharing of sensitive information.

Upon starting any clinical encounter, the provider should be prepared for the patient. In January 2020, investigators at Stanford University offered five validated techniques proven to enhance connection and communication between providers and patients.7 Known as the “Presence 5”, these five strategies foster humanism, improve communication, and establish a caring provider–patient relationship. With the onset of increased telemedicine examinations in 2020, these same investigators expanded the Presence 5 techniques to also be applied during a telemedicine visit: “Telepresence 5” (Box 1). For example, one of the five techniques is to listen to the patient intently and completely. In addition to not interrupting patients when they are speaking, the Telepresence 5 recommendation is that providers look directly at the camera to maintain eye contact with the patient, nodding and using facial expression to communicate active listening. Another technique of Presence 5 and Telepresence 5 is to connect with the patient’s story. A virtual visit has the advantage of offering a glimpse into the patient’s home environment; this provides the patient with an opportunity to share with the provider the people, pets and places of importance in their life.4

Many patients who schedule virtual appointments are concerned about respiratory symptoms. It is crucial to be able to assess how sick they are and if they need to be triaged to a higher level of care. Home monitoring devices such as a pulse oximeter, a blood pressure cuff, a heart rate monitor, or a thermometer can be very helpful to aid with the assessment. However, most patients will not have any devices that can assist in getting objective data. Thus, it is crucial that the provider hones their observational skills in assessing the patient. Excellent observational skills are essential in the in‐person setting and even more so during the virtual setting, where the environment can give the perceptive clinician many valuable clues.

Is the patient lying in bed? Is the patient tachypnoeic? Are they coughing? Are they wheezing? Are they able to speak in full sentences without having to stop to take a breath? Are they somnolent? Are they able to get out of bed and walk in place? All of these important observations can be made quickly in a virtual visit.

During the pandemic, many patients did not feel comfortable seeking care at their provider’s office for fear of being exposed to COVID‐19, preferring instead to do medical appointments for all kinds of different complaints from the safety of their own home.8

Since a hands‐on physical examination is not an option during a virtual visit, providers need to find other ways to elicit physical findings that help point towards a diagnosis. The diagnostic yield of the telemedicine encounter improves when physicians partner with the patient in performing the physical examination.9 Known as the “provider‐directed patient self‐examination,” this approach has the provider explain (and even demonstrate) the manoeuvres, coaching the patient through the performance of the examination. Upon doing so, the patient can then report physical findings. With the patient’s help, it is possible to assess areas of concern, such as enlarged lymph nodes, abdominal pain or musculoskeletal complaints, or perform a neurological examination. Of course, the reliability of the provider‐directed patient self‐examination is patient‐dependent, but many patients can be successfully coached through the basic examination manoeuvres and enjoy participating in the process.

In addition to relying on the patient to report physical findings, the virtual physical examination has other limitations. If patient safety cannot be guaranteed, it is not advised to assess a patient for dizziness with tests for balance. The thorough evaluation of a rash or skin lesion depends on the lighting and quality of the video. Sometimes, it is helpful to have the patient send photos of their skin findings to the provider. The breast or genital examination on a virtual visit requires trust and a thorough discussion of privacy issues with the patient.

Shoulder pain is a common presentation in primary care, and the shoulder examination serves to illustrate an effective use of a telemedicine examination.10 Many of the manoeuvres used for the assessment of shoulder pain in the medical office can be adapted to the virtual visit.

Similar to in‐person visits, the remote shoulder examination starts with inspection and palpation. Start by having the patient expose both shoulders. Observe for skin changes and differences in muscle tone. Next, demonstrate to the patient the areas of the shoulder that should be palpated and ask if there is any tenderness to palpation.

After the inspection and palpation, assess range of motion. As with the in‐person visit, it is easiest to demonstrate and have the patient copy the movements to assess the full range of motions. Pain with abduction between 60° and 120° (painful arc) can raise the suspicion for rotator cuff impingement.

To further assess impingement, the patient can do a modified version of the Hawkins and Neer tests. Again, it is easiest to demonstrate the manoeuvres and have the patient copy them.

Weakness in the supraspinatus muscle can be assessed with the “empty can test”. The patient can either try to hold up a weight (such as a soda can) or can use the contralateral hand to push down on the arm. The external rotation lag sign can be used to assess for infraspinatus weakness.

The evaluation of shoulder pain through telemedicine, like many other medical concerns, can yield both diagnostic and therapeutic information (Box 2).

As useful as these problem‐specific telemedicine manoeuvres can be, some patient complaints are not appropriate for a telemedicine visit. If the provider does not feel the patient’s symptoms can be adequately evaluated through a virtual medium, the telemedicine visit should be interrupted and arrangements made for in‐person care. Moreover, certain examination manoeuvres are difficult or impossible to execute across a video screen. For example, assessing for pupillary changes may be hindered in dark‐eyed patients, assessing for ligament laxity cannot be done with a remote knee examination, and it is not yet possible to do a telemedicine ear examination for ear pain.

Training providers on how to translate competence in the bedside examination into proficiency in telemedicine techniques is essential. Much can be done to prepare providers for an effective telemedicine physical examination. To fully serve our patients, providers must make sure to acquire, and teach, the competencies required for a high quality telemedicine visit.