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.
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.