By Dr Sunil Daryanani, Consultant Medical Oncologist, Yeovil General Hospital NHS Foundation Trust, Somerset, UK and Hospital de Clínicas Caracas, Caracas, Venezuela.
Telemedicine has had a very relevant role in the care of cancer patients during the COVID-19 pandemic and has been instrumental in supporting our patients. A word of caution is to be said about the changes it may be bring on after the pandemic where physical examination of our patients may no longer be felt as essential in our daily medical practice.
For clinicians, conducting a physical examination is an integral part of the general evaluation of a patient. This is particularly even more important in oncology where elements of disease, either as response or progression, toxicities to treatments and interventions and assessments of co-morbidities are of such unquestionable importance for daily practice.
A number of our decisions are based on taking a complete medical history. Conducting a physical examination is not just science but part of the art of being a physician. For generations, medical students have had to crunch and practice enormous snippets of information that only through repeated practice become part of our performance, much in the way we drive our vehicles. A well conducted physical examination will yield an enormous amount of information. It is also a means of connecting to patients and can be a powerful tool of communication1. Additionally, the possibility of diagnostic errors in clinical decision making and the recognition of patterns in cognitive errors is an area of concern for all physicians in normal instances of medical practice2.
In the last few years the recognition of less reliance on examination as a means of our medical evaluation has been widespread noted. It is a major source of concern and a number of causes have been ascribed to be deterrents of this. Clinicians are now limited by time, patients have reduced time slots and the demands imposed by electronic medical records have mandated that less emphasis is given to examination3. Clinical facilities and outpatient rooms are becoming less suited to allow examinations. Technology, imaging and laboratory tests have become surrogates in the minds of some clinicians, offsetting the subjectivity attached to eliciting physical signs and inter observer variability as common arguments. Additionally, the incorporation of other clinical members in the clinical team such as nurse practitioners, physician assistants and others may have changed the reverence given to these skills.
A number of isolated proponents of clinical evaluation have voiced their concerns and insist on more emphasis in instilling the art of examination in our medical students and trainees4. We must as clinicians continue fostering this directive. Harvey Cushing in the foreword of his book on The Life of Sir William Osler wrote “Lest it be forgotten who it was that made it possible for them to work at the bedside in the wards”5.
With the COVID-19 pandemic a number of major instances have taken place. The face of many of our practices has changed and the way we do medicine has been refashioned in order to adapt to these new circumstances6, reduce risk to our patients, protect ourselves and families and reduce propagation. The incorporation of telemedicine, in its varied guises, telephone and video consultations, webinars and online meetings have helped greatly in maintaining and sustaining our patients and their treatments; and in oncology, when compared to other specialties, a high level of activity. In some instances moving to new facilities to continue carrying out our work during the pandemic has also proven to be a major change. It is clear that the world will not be the same after COVID 19 and a number of alternative means to continue our duties have been instrumented which otherwise would have the taken enormous time to have been implemented. These are the changes and progress that are brought forward by crises and ought to be taken as a means of advancement in adverse times.
I recently saw a patient with Stage IV NSCLC with a chronic complaint of left shoulder pain whom on examination appeared to have a shoulder joint problem rather than an underlying oncological cause. A CT scan had been requested as part of his evaluation on treatment (with limited view of said shoulder) and I referred him for an orthopaedic evaluation. I received a letter from a senior physiotherapist who had performed a telephone consultation and had beautifully and elegantly described all the manoeuvres and results he had asked the patients to perform and suggested a MRI of the cervical spine to rule out an oncological cause and concluded that the diagnosis was a thoracic outlet syndrome. I was just flummoxed with the outcome. Again, only a few days ago, one of my patients with ovarian cancer on treatment with carboplatin and paclitaxel and with whom I speak every three weeks apparently was staggering as she came to treatment and I was alerted to this by one of the chemotherapy nurses. Unfortunately she now has grade 3 peripheral neuropathy which will impact negatively on her quality of life in the mid to long term. Having carefully asked her on various issues of toxicity this cheerful grandmother is of an uncomplaining disposition and would normally prefer to answer positively rather that ‘create a fuss’. An obvious caveat of conducting a telephone pre assessment.
It is therefore with caution that we ought to embrace the options given to us to institute TM very readily as our means of practising medicine in the future as it should not supplant the role of physical examination in our daily routine. Interestingly, in a Canadian study conducted before COVID-19 and presented as a poster, 83% of patients versus 45% physicians (p= 0.005) preferred TM to a face-to-face consultation7. Clear prioritisation of patient reviews during the COVID-19 pandemic is essential as exemplified in many of the tumour specific guidelines that have been published since the outbreak8. Whereas TM may prove to be a useful tool9 we must learn to use it effectively and conduct trials and assessments to learn of its advantages and pitfalls. Just positive feedback is not enough to extoll its value. I urge all to reflect on this.
1. Wolpaw D and Shapiro D (2014). The virtues of irrelevance. N Engl J Med 370 1283-8.
2. Restrepo D, Armstrong KA, Metlay JP (2020). Annals Clinical Decision Making: avoiding cognitive errors in clinical decision making. Ann Intern Med 172 747-752.
3. Okie S (2012). The evolving primary care physician. N Engl J Med 366 1849-53.
4. Verghese A (2008). Culture shock - Patient as icon, icon as patient. N Engl J Med 359 2748-51.
5. Cushing, Harvey (1940). The Life of Sir William Osler. Oxford University Press, New York .
6. Segelov E, Underhill C, Prenen H et al (2020). Practical considerations for treating patients with cancer in the COVID-19 pandemic. JCO Oncol Pract 1-16.
7. Gondal H et al (2019). Patients and physicians’ satisfaction with Telemedicine in cancer care and factors that correlated with a positive patient’s experience. Ann Oncol 30 (suppl 5) Abstract 2281.
8. Passaro A, Addeo A, Von Garnier C et al (2020). ESMO management and treatment adapted recommendations in the COVID-19 era: lung cancer. ESMO Open 5 e000820.
9. Sirintrapun SJ, Lopez AM (2018) Telemedicine in cancer care. ASCO Ed Book 540-545.
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