#MSCOVID19: the new normal

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The new normal is the not laying on of hands. 

Social distancing applies to inpatient care as well. The diktat from infection control is to limit the amount of direct contact we have with patients, especially vulnerable patients, to reduce the inadvertent spread of SARS-CoV-2 between HCPs and patients. I am finding this very difficult. I was trained and practised medicine were the clinical examination was revered; it was the one skill that differentiated us from other HCPs. Interestingly, what has become clear to me is that you can largely manage patients with metrics that are not dependent on the clinical examination. Just maybe, Professor Chris Hawkes, a colleague of ours, was right when he said he doesn’t have to examine his patients anymore (see below). I was so outraged by the article that my mentor (Prof, Vivian Fritz) and I wrote a rebuttal (see below). It is interesting to read our words 10 years later in the middle of the COVID-19 pandemic where we have been advised to try and avoid the physical examination. 

The remarkable thing is that I have been able to get away with not examining about 90% of the patients I have seen in the last two weeks. Even my outpatient work has moved onto a telemedicine platform and is being done via an online video link. Will this become the new normal? In the future, I envisage you all being asked to sign-up to completing a self-monitoring protocol, for example, the web-EDSS, 9HPT, T25W, daily activity monitoring, BP, pulse, body weight, cognition (online or smartphone app assessment) and a set of PROMs (patient-related outcome measures) every 3-6 months. You will have your regular bloods and annual MRI monitoring done close to where you live and the results and images will be analysed by an AI-bot and the metrics automatically loaded into your electronic patient record. All this information will be collated and summarized in a dashboard that is shared between you and your neurologist so that when the video consultation happens it can be done as efficiently as possible in a standardised format. 

As a person with MS, the question is how do you feel about not being examined by your neurologist or having face-to-face visits? What about having a standardised and highly-automated follow-up appointment? 

Already our managers are asking us what parts of the COVID-induced reconfigured NHS services do we want to keep? As the patients or clients, we should be asking what you want? For example, should I continue to run my online MS&COVID-19 Q&A service, but widen it to MS in general? In reality, this Q&A service is morphing into micro-consultation service. Could this be something we expand as a Barts-MS service? 

Hawkes CH. I’ve stopped examining patients! Practical Neurology 2009;9:192-194.

Image from Chris Hawkes, Practical Neurology.

Professor Gavin Giovannoni and Professor Vivian Fritz. A plea to neurologists, especially privileged British neurologists. Practical Neurology Published on 1 March 2010. 

Sometimes it is necessary to make a point with overemphasis and we believe that was done in the letter by Chris Hawkes. We agree that it is essential to talk to a patient and to watch them and observe how they speak, what they are saying and what they are doing with their body as they walk in and out of a room. However, to exclude the examination is a form of conceit. The only reason that a very senior neurologist can observe so much is from a long period of diligently examining all patients and slowly learning shortcuts by pattern recognition. But you can’t teach neurology that way. Students must first be taught the discipline of a routine in order to learn which part of the routine can be discarded in individual patients. When a TIA is caused by atrial fibrillation a finger on the pulse will lead you to the ECG as the first test. A stethoscope on the neck will suggest that a Doppler should happen immediately. When resources are limited (which occurs in much more than half the world) it is important to direct your tests sensibly rather than blindly ordering a battery. If a student can’t distinguish between an upper and lower motor lesion then the differential of a paralysed limb trebles and an EMG, as well as an MRI, needs to be done routinely. We are not against spending more time talking to a patient, even if it means less time examining, but don’t eliminate the examination. It’s like throwing the baby out with the bathwater. When in doubt the most cost-effective investigation is to retake the history and to examine the patient. We mustn’t forget that an essential part of any consultation is to gain the trust and respect of the patient; if a patient doesn’t trust the consultant they are unlikely to accept the diagnosis and treatment plan. We have all seen patients for second and third opinions when on completing the examination they compliment you on how thorough you have been and inform you that their previous consultants hadn’t bothered to examine them. The “laying on of hands” is as essential to today’s consultation as it was in the past. In today’s litigious environment not examining a patient would be welcomed by the opposing legal team with glee. We doubt any expert witness would support the notion of not examining a patient as standard clinical practice. In the new era of revalidation admitting to your peers that you do not examine your patients would be inviting an early retirement or a change in career.

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.

19 comments

  • I would absolutely love you to continue your online Q&A post covid. I find it so helpful and reassuring. It keeps me up to date. It means that I feel one step ahead of the game in my MS care throughout the crisis.
    Thank you so much for the service!

  • Last week I had the best appointment I’ve ever had with a sleep neurologist. There is huge value in removing the cognitive dulling of a six hour return trip, on top of the time and financial hit.

    I’m thrilled that for some specialities, this situation has boosted telemedicine options.

    I watched an interesting “how to perform a virtual neuro exam” this morning.

    This may be a game changer.

  • “ For example, should I continue to run my online MS&COVID-19 Q&A service, but widen it to MS in general? In reality, this Q&A service is morphing into micro-consultation service. Could this be something we expand as a Barts-MS service? ”
    Don’t you already do this as part of this blog? – No specific advice but general comments.
    I think that teleconsults should be kept for when they are needed, because a patient is not able to attend a face to face appointment, they really shouldn’t become the norm. Most people need face to face interactions with other people…. I’m not necessarily one of them, but I know many people stuggling with being in lockdown, simply because they don’t get to see/talk to other people. If we keep all these virtual ways of “interacting” then mental health issues are going to increase (both in pwms, and people without ms.

  • I never understood what that little toy hammer is for anyways….

    Since EDSS is not a good proxy to underlying disease activity, why assess it?

  • I can see this would be fine in principle and I wouldn’t mind at all seeing my neuro through a screen. But – as is inevitable – when there is a change in staff and I am now expected to interact with someone I’ve never met in person it is very much less good. As for physical examination, since diagnosis in 2003 I have never been physically examined by a neuro except when attending relapse clinic – and I am at a centre of excellence. I dread having blood tests and MRIs done locally – we’re so understaffed and the hospital is ‘requiring improvement’ on all counts. So much easier to travel to a place where systems work well but I guess not if you catch coronavirus en route. This has depressed me!

  • Yeah seeing patients is so tedious if only you could class them all as covid patients then ms would be eradicated completely! New normal is a phrase banded around to liberally at the moment, end the pointless lockdown and admit like all viruses it is going to have to run its course, otherwise there will be nothing to go back to. Some government scientific adviser advocating 18 month lockdown on BBC this lunchtime, ludicrous there would be no jobs to go back to if that happened. Also think of all government employees pensions and that includes all nhs employees whose pensions would evaporate as no taxes could be collected. Protect the old and vulnerable groups and END THE LOCK DOWN if you let have any sway start pushing back or the blood in the streets wont be just the blood of your patients it will be yours when the starving masses reject the world that is being forced upon them. Think on the future.

  • There is something reassuring about having a clinical exam which validates your personal experience. I like the confirmation that my symptoms are indeed neurological and not psychological. I also think that body language is a huge aspect of communication that is lost through a telephone conversation, and tricky even with video conferencing.

    I haven’t had a neuro appointment over the phone, but have had one with urology. It might improve with practice on both parts, but I realised after hanging up the phone that I hadn’t asked half of the questions that I meant too….

    • Exactly my thoughts too. I’ve read doctors write that often with a patient it’s what they DON’T say sometimes (and their body language), that matters more than what they do say?

      Though my GP tells me a lot of her patients like coming in just for a chat!

      As a patient I value seeing someone IRL. Particularly if it’s someone you’ve never met before. It’s hard to trust someone through a video, it would be even harder to trust someone via video that you’ve never met (and I am a young person who has grown up on the internet). Also there are other factors like having a totally private space to have the call too. If you are self conscious someone in your household can hear you, you may not be as honest or say what you really want, that you’d feel more comfortable saying in the safe space of a totally private hospital room.

      I think for things like medication reviews video would be ok. But for examinations or new problems – in person may win out (if I had a choice). At the end of the day though, you guys are the doctors and am sure you’d make the right decision and perhaps it’s all a case by case basis?

      If it saves you all time and money to be able to run things more efficiently and effectively for more patients too, that can only be a good thing.

      For older people who are not as technically savvy, or more disabled, it might be harder. Also people who are lonely or not used to social interaction on videos chats.

      • P.S Forgot to add, the microsite for Covid is amazing and has been so helpful! And, as is this blog already and the monthly Q&A you guys do. If this was more of an official thing for patients to write in I bet that would save so much time for everyone.

  • As someone with PPMS I would welcome having remote consultations with my neurologist; I only see him once a year (actually more like once every 15 months) and have no examination. I need to continue to see him so that he can sign off that I am fit to drive when my renewal comes around every 3 years – this takes several months for him to deal with – and so that he can respond to the DWP if they require him to. A remote consultation would be easier for me and I would lose nothing.

  • The examination by the neurologist when I presented with brainstem sensory symptoms was, for me a real eye opener. To add to my presenting relapse he added: mild INO, lost abdominal reflexes, abnormalities in the leg reflexes, and to my surprise, my terrible heel to toe walking. The fact that I then forgot where I had parked my car in the hospital added to the insult.

    I left the appointment shellshocked to learn that my MS was far more widespread than I thought. It also made me look at every aspect of my lifestyle with more enthusiasm, indeed, urgency. I will not forget that day.

    There is also something unique about being examined, beyond that deduced by the examiner. Not sure what to call it, perhaps respect. It can be healing.

    However, needs must. Perhaps imaging will fill the gap, but there will be something lost. Perhaps less significant than the loss of risk the examination poses to health staff. With the loss of experience of performing it again and again and having the findings validated (or not) the examination might well join the list of incredible skills that will have become extinct.

  • ‘For example, should I continue to run my online MS&COVID-19 Q&A service, but widen it to MS in general? In reality, this Q&A service is morphing into micro-consultation service.’

    Over time, and some unpleasant and frustrating experiences, I seem to have developed a fear/distrust of doctors/hospitals/treatments. My ms is untreated, as are my comordities, all are worsening. I have questions but nowhere to ask them where they will be answered. I can’t be the only person to have got into this mess. Telemedicine may be a good idea for some people.

  • I live an 8 hr drive or an un-reliable flight from my neurologist so have had a mix of in person and telephone appointments. My last relapse I really wish I had gone in person. While at one level my neurologist believes me on another I don’t think he really understood how bad things actually were. I’m not a normal patient in that I do things like continue to run even though it means falling down more often than I care to admit. This means an answer to a some questions like continuing to exercise make me sound like I’m doing better than I am. I try very hard to be extremely factual and keep a log but seeing is believing. For example I have a very unique breathing issue, I had videoed it happening but no-one really wrapped their head around it until it was seen in person.

    I’ve also got a friend with MS who is the king of denial. He’s always great even though its very clear that he’s deteriorated dramatically in the handful of years I’ve known him. I can see him hiding many of his physical problems if just a video or phone were used.

    So at the end of the day I think a mix is important. Personally I would like to do some of my appointments virtually and some in person. I have one coming up end of May that I really hope can be in person because I feel the need for my neurologist to see and not just be told where things are at. I’ve been lucky in that my neurologist has really been very flexible though this time we may not have a choice.

  • There is something very human about the laying on of hands from a healer. Something more ancient than medicine, I think. We will still be human post the Wuhan Coronavirus and we will go back to that.

    We will also use other tools, I don’t know what they will be yet. There is going to be a great deal of change post this virus.

  • On the fence regarding the exams (some seem more useful than others but it depends on the specific patient in question [1]) but I would very much like to encourage you to keep adding to the Q&A – a resource like that is invaluable and a great multiplicator for your work!

    [1] Grip strength annoys me in particular, there barely goes a day that my hands do not hurt (and have done so for 7 years, 6.5 of which nobody out of at least 6 doctors was any wiser regarding my MS despite racking up other symptoms along the way) but if you tell me to squeeze, I can do that like most people. Typing on the other hand is often difficult and handling dishes occasionally too…

  • I hope the telehealth appointments continue. I find the trip to and from the appointment and the long wait time to see the dr very physically exhausting.

  • Great article! I feel uneasy as well about letting go of a good neurological examination with video visits. But in all fairness, it works very well for established patients especially the ones who are stable, cannot walk freely or have longer commutes. It does not work very well for us for newly diagnosed people or people who are coming in for a relapse. Neurological examination is a fine art that is essential for me to make a diagnosis.
    But here we go, learning to adapt to the new situation, hands free neurology. I wonder what the patient satisfaction scores will be with this and how this would affect the doctor patient relationship with the lack of human touch !

  • Great article! I feel uneasy as well about letting go of a good neurological examination with video visits. But in all fairness, it works very well for established patients especially the ones who are stable, cannot walk freely or have longer commutes. It does not work very well for us for newly diagnosed people or people who are coming in for a relapse. Neurological examination is a fine art that is essential to make a diagnosis.
    But here we go, learning to adapt to the new situation, hands free neurology. I wonder what the patient satisfaction scores will be with this and how this would affect the doctor patient relationship with the lack of human touch !

  • I would prefer to see my neurologist face to face. It makes me feel valued. It continues the relationship of trust. This enables me to ask questions.

By Prof G

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