One Additional New Commonsense Quality Metric

Abstract

I thoroughly enjoyed and, utterly support, Eric Cohen's suggestion of 5 new commonsense quality metrics1Cohen EP Five commonsense metrics: a commentary and a proposal.Am J Med. 2023; 136: 15-16Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar but would like to suggest a sixth unexpected one: Examining the patient. On a recent visit to a friend's clinic, I was stunned to see his empty waiting room because he is a trusted primary care physician caring for hundreds of patients. “It is mostly done over the telephone and internet today,” he explained, referring to the prevailing habit of “a light finger on the trigger” of ordering laboratory tests and imaging and freely scheduling appointments with myriad consultants. Indeed, my own ambulatory patients often tell me, “I have never been examined like this,” although I did no more than a quick overall examination. Unfortunately, these personal observations are supported by research. Time-motion studies reveal that internal medicine residents in the US or Canada spend a mere 9%-12% of their time in direct patient care (68 minutes of the work day, 8 ± 6 minutes per patient) versus 40%-51% on computer work.2Fletcher KE Visotcky AM Slagle JM et al.The composition of intern work while on call.J Gen Intern Med. 2012; 27: 1432-1437Crossref PubMed Scopus (44) Google Scholar,3Mamykina L Vawdrey DK Hripcsack G How do residents spend their shift time? A time and motion study with a particular focus on the use of computers.Acad Med. 2016; 91: 827-832Crossref PubMed Scopus (75) Google Scholar Likewise, in primary care, the electronic health record (EHR) seems to take most of the visit time (eg, 16.25 min of a mean 18.0 min), and patient examination is barely studied.4Overhage JM McCallie Jr., D Physician time spent using the electronic health record during outpatient encounters: a descriptive study.Ann Intern Med. 2020; 172: 169-174Crossref PubMed Scopus (98) Google Scholar No wonder that the use of tests is rapidly increasing5O'Sullivan JW Stevens S Hobbs FDR et al.Temporal trends in use of tests in UK primary care, 2000-15: retrospective analysis of 250 million tests.BMJ. 2018; 363: k4666https://doi.org/10.1136/bmj.k4666Crossref PubMed Scopus (73) Google Scholar and, with it, the incidence of false-positive results, begetting more tests. Time constraints and overreliance on tests and technology have led to an atrophy of clinical skills,6Jauhar S The demise of the physical exam.N Engl J Med. 2006; 354: 548-551Crossref PubMed Scopus (95) Google Scholar indispensable for eliciting positive and negative information in real time and for the patient-physician relationship,7Schattner A Revitalizing the history and clinical examination.Am J Med. 2012; 125: e1-e3Abstract Full Text Full Text PDF PubMed Google Scholar fostering a vicious cycle of more testing/referrals, and furthering providers’ decline in their ability to examine the patient. This unwelcome trend has been further accelerated with the necessary adoption of “virtual” visits during the coronavirus disease 2019 (COVID-19) pandemic.8Gelfman DM Will the traditional physical examination be another casualty of COVID-19?.Am J Med. 2021; 134: 299-300Abstract Full Text Full Text PDF Scopus (0) Google Scholar Thus, physical examination is often perfunctorily performed, yet should remain a powerful tool in diagnosis, once interpreted in the context of the patient's history and performance characteristics of each examination.9Simel D Drummond R The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. 2008; Google Scholar Its inclusion among quality metrics is a useful reminder to clinicians of what is well-known but often skipped.