When I started my medical training in 1984, the general understanding was that clinical history contributed about 70% to establishing a diagnosis, with physical examination and investigations contributing about 20% and 10%, respectively. Since then, remarkable advancements in medical imaging (MRI became widely available only in the early 1990s), other rapidly advancing technologies, practice pressures, and virtual care have all influenced the role of the physical exam.

WorkSafeBC depends on external information to adjudicate a worker’s claim and relies on the information physicians submit to support the worker’s treatment and recovery from a workplace injury or illness. When a WorkSafeBC medical advisor (a physician) reviews claims, they also review the examination findings from attending physicians. Missing or incomplete findings can impact a worker’s entitlement to WorkSafeBC benefits such as physiotherapy and expedited assessments, investigations, and surgery. Missing information also makes it difficult to identify safe options for a graduated return to work, which can imperil a worker’s livelihood.

Looking closely at an injury with persistent symptoms

Imagine the following patient comes to see you for an injury that occurred at work. Bob is a 54-year-old construction worker who has been your patient for over 20 years. He notices a sharp pain in his right knee while straightening up after bending to the right to pick up a box of nails from the ground. Bob has seen you several times over the past 10 years for episodic pain in his knees; X-rays have shown mild osteoarthritis. Bob shrugs off the pain and completes his shift. Bob’s knee feels worse the following day, and he is able to schedule a telehealth visit in 2 weeks’ time. Bob submits a claim for his knee and informs his employer that he is not able to work due to the pain.

At a virtual assessment 2 weeks after the work incident, Bob reports that his knee feels a bit better. The swelling is almost gone, but descending stairs is uncomfortable. You diagnose a sprain/strain of the knee. Bob states that his knee is too sore to go back to work and wonders about taking more time off. You recommend 4 more weeks off work, physiotherapy, and an NSAID, and you schedule a follow-up telehealth visit. At follow-up, Bob informs you the swelling is gone and his knee feels mostly back to normal, except for occasional stabs of pain when squatting. When you suggest Bob try working, he asks why his knee is still sore and then asks if it is safe to resume working on ladders.

At this point, WorkSafeBC may have additional interventions to help Bob throughout his claim and return to work. To assist with interventions, WorkSafeBC medical advisors may be asked to provide opinions on the diagnoses provided by community physicians. Physical examination findings are an important part of the information reviewed. An accurate diagnosis ensures a worker receives appropriate treatment and receives the benefits to which they are entitled. Returning to your patient, Bob, stabbing knee pain persisting for 6 weeks is atypical for a sprain/strain. A physical examination can help differentiate between worsening osteoarthritis of the knee, meniscus injury, sprains of the cruciate or collateral ligaments, tendon injuries, and nontraumatic conditions. An accurate diagnosis with physical findings allows WorkSafeBC to find appropriate resources to help Bob recover and helps increase the chance of him preserving his livelihood.

Putting it together

Evidence shows that telemedicine is better suited to some patients than others and is most suitable for stable patients with chronic disease who have an existing relationship with their physician.[1] The Canadian Medical Protective Association calls the physical exam “a powerful tool” for improving the accuracy of diagnoses and cautions that “how you perform the physical exam, and how often you perform it, can change over time and become overly limited without you realizing the impact on patients.”[2] Performing a physical exam can also increase patients’ confidence in the physician and validate that they have been heard.

If you have questions about your patients with workplace injuries/illnesses and would like to speak with a physician at WorkSafeBC, please contact us through the RACE app at www.raceconnect.ca/race-app [10].
—Harvey Koochin, MD
Manager, Medical Services, WorkSafeBC

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This article is the opinion of WorkSafeBC and has not been peer reviewed by the BCMJ Editorial Board.

[11]

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License [11].

References

1.    Lee PS, Koo S, Panter S. The value of physical examination in the era of telemedicine. J R Coll Physicians Edinb 2021;51:85-90.

2.    Canadian Medical Protective Association. What happened to the physical exam? Last modified October 2021. Accessed 16 October 2023. www.cmpa-acpm.ca/en/advice-publications/browse-articles/2019/what-happened-to-the-physical-exam [12].