The importance of physical examination in primary health care provided by NPHW is being threatened in COVID19 times

Abstract

Physical examination has been one of the three pillars of diagnostic evaluation of illnesses. It has a larger role in the armamentarium of non-physician health workers. Due to prescriptions for social distancing in preventing COVID19, physical examination is being performed lesser than before. This poses a serious threat to the abilities of NPHW as well as to their relationship with the community.

After training and practicing in large teaching hospitals in urban areas, when we moved to a rural hospital in central India, one thing which patients did exasperated us. When we requested patients to lie down for physical exam after the history taking, they would often lie in a prone position. Patients lying prone instead of supine were unusual for us. A few months later, after spending time in the clinics we learnt that patients in this region, always lay prone as they assumed the only reason why they would be asked to lie down was for an intramuscular shot. Of the three parts of the diagnostic evaluation, in most low resource situations, a hastily taken history would be considered enough for a diagnosis in the absence of any physical examination and absent diagnostics.

Role of Physical Examination in Primary Health Care

Of the three pillars of the diagnostic evaluation, physical examination allows one to confirm the diagnosis that is suspected on basis of the history without any additional expenditure. Physical exam also informs us about the pattern and the severity of the disease. It also allows one to rationally plan the next pillar of diagnosis- choosing laboratory investigations. Contrarily, etiology of the disease is suspected on history and confirmed on laboratory test results with examination playing a minor role.

Not performing or doing a poor physical examination are a threat to patient safety as the probability of diagnostic errors and oversights is increased.[1] A careful physical exam can help a clinician refine the next steps in the diagnostic process, can prevent unnecessary diagnostic testing, and can aid in building trust through touch, with the patient.[2]

In our work to develop good models of primary health care, we focus on training and mentoring non physician health workers (NPHW) at the village level so that much needed primary health care is accessible. Thus, we developed training modules in diagnosing most common and important illnesses for NPHW that included physical examination skills as needed. As we look back, we realize that our training processes were longer, required frequent iteration and more mentoring than conventional training programmes for NPHW.

We realized that there were over 24 different types of examination that our NPHW were performing in their diagnostic work up. Table 1 summarizes these examinations along with the illness diagnosed be them.

Table 1.

Physical examination being performed by the Non-Physician Health workers

Physical examination	Diagnostic/therapeutic utility in primary health care
Measuring Temperature	Fever, Hyperthermia, Hypothermia
Checking the pulse	Pulse rate is a critical vital measure
Blood pressure measurement	For hypertension, or estimating sickness in systemic infections
Weight check, height check	Nutrition and anthropometry measurement
Pallor/jaundice exam of palmar creases and of lower and supra-corneal conjunctiva in the eye	Confirming presence of severe anemia and of jaundice
Throat exam, neck lymph node exam	For fever and throat pain to look for pharyngitis
Exam for pedal edema	For heart failure, for severe protein malnutrition and for other reasons of hypoalbuminemia.
Checking skin turgor	Dehydration assessment in gastroenteritis
Newborn care- mopping,	Essential newborn care at birth
Ear exam with torch or otoscope	For ear infection or foreign body or pustule or mopping pus
Breast exam for malignancy, nipple formation in pregnant and lactating women	For suspecting a breast malignancy or an abscess and for well-formed nipples so that breast attachment in feeding be assessed.
Auscultation of the chest	Distinguish various lung and pleural cavity illnesses
Cardiac auscultation.	Examination for life, and to pick up a murmur or signs of CHF
Palpation of the abdomen for an abdominal lump	Narrow down differential diagnosis
Spleen enlargement	Considering malaria or enteric fever in a febrile person
Abdominal exam for pain abdomen for quadrant of pain	In evaluation of acute abdomen
Umbilical examination	For umbilical infection and discharge
Abdominal Palpation for uterine size and lie.	Key assessment of fetal growth antenatally and lie
Per Speculum/Per Vaginum Exam	Examination of infection, or screening of a malignancy of the reproductive tract, or insert a Intrauterine contraceptive device
Examining perianal area	Fissure in ano, or external hemorrhoids, or for fistula in ano
Leprosy nerve examination	For neuritis and for nerve enlargement in leprosy, and for neuroanaesthesia
Blood sampling	Drawing blood sample for laboratory tests, from a capillary or venous route
IM Injections for acute psychotic episodes	emergency management of someone with Acute psychosis
Wound Dressings	Cleaning and dressing of lacerations and abrasions and burns

This process of diagnostic evaluation, like other processes is liable to trivialization in periphery-based care, which is where most primary health care is practiced. And it is in the availability of laboratory testing and in physical examination that this trivialization mostly manifests.

Impact of COVID19 on Physical Examination

When the COVID-19 epidemic hit India, and concerns about its rapid spread to rural areas emerged, health care systems for non COVID-19 illnesses were challenged, and shift of focus to COVID-19 care was felt all over. A striking observation we made was the elimination of physical examination of patients seeking care. Arguably health workers were doing this to minimize the risk of getting infected and in line with the advice to observe physical distancing.

Since the beginning of COVID-19 pandemic, healthcare workers in both COVID-19 and non COVID-19 care facilities maintain a distance of 1 to 2 meters from patients. Checking pulse or mere touching of hands or a handshake has been replaced, if at all, by an oximeter applied to the fingers. Even critical examination is not being done, for example, abdominal examination for uterine height or examination of the chest with a stethoscope in someone with fever and cough is not being performed.

The proportionate role that physical examination plays in primary health care is larger than in secondary or tertiary care, simply because availability of laboratory investigations as the third pillar is poorer. The unnecessary reliance on investigations has made it harder for modern-day physicians to meet the day-to-day needs of patients seeking medical care, especially in resource-limited settings.[3]

For example, a good examination of the uterine fundal height and of the lie of the fetus in an antenatal clinic in the peripheral clinics may reduce the need for doing sonography in all pregnant women. Our health workers can auscultate for rhonchi or wheeze and thus are able to confidently diagnose reactive airway disease. Examination of the abdomen in a young man who presents with an acute abdomen and vomiting might hasten the referral of a person with acute appendicitis to a surgical facility.

Telemedicine is being offered as a solution to improve access to clinical diagnosis and treatment especially in the peripheral health facilities,[4] and is being encouraged in these pandemic times.[5] Telemedicine suffers from larger emphasis on history and on some point of care tests and hardly any physical examination, which poses limitations to its effectiveness in reaching a clinical diagnosis.[6,7]

Threat to Primary Health Care Provided by Non physician Health Workers

Due to instructions handed down to the peripheral workers compounded by the media blitz about the risk of COVID acquisition, NPHW have also stopped doing physical examination as part of their diagnostic evaluation. Trust in their clinical skills and personal rapport they had built with the community they had served are seriously at risk due to physical examination having disappeared in the armamentarium of the NPHW. We should provide appropriate personal protection equipment to all NPHW and allow them to continue with their important work in primary health care.

Community level health workers that we work with are especially upset at these developments. One, they find their ability to reach a diagnosis compromised frequently. Two, they fear losing skills in doing certain examination in case this recent trend sustains. Three, they already see the carefully built over the year trust of the communities in non- physician health workers eroding. This loss of trust in NPHW poses a serious risk to primary health care for communities in low resource areas.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.