Is it acceptable to forgo a physical exam during a video visit?

Video Visits and Physical Examinations: Guidelines and Best Practices

While a conventional physical examination cannot be performed during video visits, a self-examination directed by the physician is a reasonable alternative, especially in video visits. 1

Limitations of Video-Based Physical Examinations

• During video visits, it is not possible to perform a conventional physical examination, which is a significant limitation of telemedicine 1
• It is also not possible to obtain ancillary tests (such as urine dipstick, postvoid residual urine measurement, and laboratory testing) during the encounter; therefore, any important tests that are required have to be conducted separately 1
• Some conditions may require in-person examination more than others - patients with chest pain (52% vs 18%, p = 0.0007) and joint pain (24% vs 8%, p = 0.05) had significantly higher rates of in-person follow-up after video evaluation compared to office visits 2

Acceptable Alternatives to Physical Examination

• A self-examination directed by the physician is a reasonable option during video visits 1
• Physicians can document a limited physical examination by guiding the patient through it during video visits 1
• For certain specialties like mental healthcare, physical examination is often not essential, making telehealth particularly suitable 3, 4
• For heart failure patients, limited examinations can be accomplished via video, including assessment of fluid retention (by the patient feeling for leg edema), blood pressure with pulse rate and rhythm, and oxygen saturation 5

Guidelines for Conducting Video Visits

• During video visits, ensure a quiet and private environment for both provider and patient 1
• The patient should preferably be alone or with a relative who may help with technical issues 1
• Laptops and desktop computers are preferable to cell phones for video visits 1
• Ensure adequate lighting with good audio and place the camera at eye level 1
• Wear professional "work" clothes and manage your body language while analyzing the patient's body language 1
• Offer advice to perform a guided physical self-examination 1

When In-Person Visits Are Necessary

• Patients at risk for melanoma and nonmelanoma skin cancer should be seen in person at a frequency consistent with standard of care for a full skin examination 1
• New patients establishing care may benefit from in-person visits 1
• Patients experiencing unstable disease/flares should be considered for in-person care 1
• Patients requiring a thorough skin/joint examination and a full physical examination for rheumatology patients should be seen in person 1

Evidence on Safety and Efficacy of Video Examinations

• For abdominal pain, a study found 80% agreement between telehealth and in-person clinicians on the need for imaging, suggesting caution is needed but video assessment may be feasible 6
• Another study found that telehealth physicians did not miss the identification of imaging needs for patients requiring urgent or emergent surgery for abdominal conditions 7
• Video visits appear to be generally adequate for evaluating headache and abdominal pain, while patients with dizziness and chest pain have higher frequencies of in-person and Emergency Room follow-up within 3 weeks 2

Patient Perceptions and Preferences

• Patients report overall satisfaction with video visits, with the majority interested in continuing to use them as an alternative to in-person visits 8
• Primary benefits cited by patients are convenience and decreased costs 8
• Some patients feel more comfortable with video visits than office visits and express a preference for receiving serious news via video visit, because they can be in their own supportive environment 8
• Primary concerns with video visits are privacy, including the potential for work colleagues to overhear conversations, and questions about the ability of the clinician to perform an adequate physical examination 8

Documentation Requirements

• It is important to document all data in the clinical record as with face-to-face consultation 1
• The note should include a disclaimer, such as "teleconsultation is provided with the consent of the patient" 1
• Documentation should include patient consent to telehealth arrangements, method of monitoring and communication, and specific accommodations being provided 3

In conclusion, while physical examinations cannot be performed conventionally during video visits, guided self-examinations and visual assessments can provide valuable clinical information in many cases. However, providers must recognize the limitations of video-based examinations and arrange for in-person follow-up when necessary.