By Matthew M. Tomaino, MD, MBA

My practice consists of 50% shoulder and 50% hand and elbow. And even though only 15% of my patients have elected a “telemedicine exam” since the Covid-19 crisis began, my newly minted “telemedicine” experience has illuminated the following:

1. The value of the “exam,” and more importantly my “assessment,” is optimized by the quality of my “engagement” — the human connection I make. So, I have spent even more time doing this than I ordinarily do during an in-person office visit. Why? Because I assume that anxiety is high, regardless of whether it is acknowledged. I deliberately attempt to demonstrate empathy with questions like: How are you hanging in there with this crisis? Are you working? How is your family? What are you doing to stay positive?
2. My “examination” of the shoulder, hand, or elbow begins by my asking the patient for their self-assessment of pain, function, and satisfaction with their progress.
3. Whether it be via iPhone or Google Duo (if they have an Android phone), I then ask for a demonstration of range of motion. My assessment is admittedly binary—normal or limited. The number does not matter. Equally valuable is to ask whether it is painful.
4. At this point I share my assessment, which may range from “It seems like you are doing well, do you agree?” or “It seems like you’re not doing very well, do you agree?”
5. Then, while making certain that I sit squarely on my chair, and while making the best eye contact possible given the technology, I discuss an action plan that will be “responsive” to the patient’s answers/concerns.

What I have learned will likely be enduring. Firstly, despite the “academic” relevance of several “data points” from a typical upper extremity examination (motion, stability, grip strength, tenderness, etc.), the telemedicine exam facilitates, because of its inherent limitations, a “high altitude assessment” of function (or dysfunction), based more on patient self-assessment than my physical exam.

Second, this constraint has helped me appreciate the compensatory value of truly appreciating “how the patient is feeling.” While I have historically aspired to look at patients in the office holistically, I realize, based on this telemedicine experience, that it’s quite easy to move to the “physical assessment” almost immediately and to make the “shoulder, hand, or elbow exam” the feature of the encounter.

To summarize—a far less optimal physical assessment via telemedicine illuminates the value of the “human connection.” Listening, observing and appreciating our patients before examining (their arm) is informative. As a physician, who happens to be a shoulder, hand, and elbow surgeon—my value to the patient is no less via telemedicine— but it relies on being physician first.

Despite a mere video encounter, without laying my hand on the patient, smiling, listening, being positive, and conveying empathy helps patients understand that I fully care about their recovery.

Matthew M. Tomaino, MD, MBA
Tomaino Orthopaedic Care for Shoulder, Hand, and Elbow, LLC
Rochester, New York