Physical Exams Add Less Than 5 Minutes to Neurology Consults

A hands-on neurological examination adds

The findings, published online on December 4 in Neurology: Clinical Practice, appear to support earlier claims by clinical neurologists that an effective physical exam can be performed in the space ≤ 5 minutes.

For their research, John Ney, MD, of the Yale School of Medicine, Yale University, in New Haven, Connecticut, and colleagues looked at records from new patient and follow-up neurology visits captured in the National Ambulatory Medical Care Survey (NAMCS) from 2012 through 2016. The NAMCS collected data from physicians at nonfederal hospitals and freestanding centers about each outpatient visit, including estimated time spent on specific clinical activities. All patient visits recorded in the survey were in person.

Altogether 58% of the visits captured in the study included a neurological exam. Ney and colleagues found that physicians spent a mean 29.9 minutes with patients in visits with an exam and 25 minutes in visits without one (P = .002). After data were adjusted using probability weighting, new visits were associated with 4.1 more minutes with the patient when an exam was conducted, while follow-up visits added a mean 4.6 minutes.

The researchers described the finding of longer follow-up vs new visits as unexpected but surmised that “time spent with established patients [may represent] an average of both higher intensity, more complex, and more time-consuming examinations,” such as cognitive testing, as well as “shorter, more focal neurologic examinations (eg, for carpal tunnel syndrome).”

Visits for pain complaints and known neurologic diagnoses were significantly longer, the investigators found, adding a mean 6.7 and 7.5 minutes, respectively, to the visit time. Exams were more common for patients on Medicare.

‘A Vital Diagnostic Tool’

Few neurologists would dispute the value of a physical examination, which, unlike in other specialties that have come to rely more heavily on lab work and imaging, remains “a vital diagnostic tool” in neurology, Ney and his colleagues wrote. Nonetheless, “it takes time to perform, and physician time has a cost.” Future studies to evaluate how an examination, or lack thereof, affects the use of imaging, laboratory tests, medication changes, and consultations “would better define the tradeoffs between this service, diagnostic accuracy, downstream costs, and quality of care.”

The fact that physical examinations were not conducted in more than 40% of visits captured in the study, Ney and colleagues wrote, “suggests that telemedicine, by video or by phone alone, may be appropriate” for many neurology visits, noting that some elements of the neurologic examination have been adapted for telemedicine, and that neurologists are “learning to weigh the value of those examination elements that can be determined remotely.”

The 5-Minute Neurological Examination

For two decades Ralph F. Józefowicz, MD, of the University of Rochester Medical Center in Rochester, New York, has lectured on what he calls the “5-minute neurological examination,” an informal guideline he developed. The study authors cited a recent talk by Józefowicz, noting that their findings “comport with at least some claims of the time required to reliably perform the neurologic examination.”

In an interview, Józefowicz explained that he designed the 5-minute guideline to help nonspecialists. “A lot of physicians who are not neurologists hate neurological examinations because they can be overly detailed. My idea was that everyone could learn how to do a 5-minute exam that’s going to be high yield, that will not unduly prolong the visit and will give you the information you need.”

The new findings underscore that the 5-minute target applies in neurology settings too. Much of the exam “is done by just observing the patient when you’re taking a history,” Józefowicz said. “If you don’t do the examination, you’re likely to waste time, waste money, and possibly make the wrong diagnosis because many disorders won’t have imaging abnormalities,” he said. Overly detailed examinations, meanwhile, “can cloud the picture with incidental findings, and send you down rabbit holes.”

Other Concerns

Older people with gait abnormalities or cognitive issues will take longer to examine, Józefowicz acknowledged, and many follow-up visits, such as for migraine complaints, may not require an exam at all. Certain patients who have had neurologic examinations in the past, including patients with migraine and those with stable seizure who only require consultation for medication management, may be good candidates for telemedicine visits, he said.

Ney and colleagues reported among limitations of their study that it relied on physicians’ own estimates of time spent; that there were few details about the nature of the exams; and the data did not necessarily reflect current practice. During the study period, they noted, coding guidelines “included financial incentives to perform a more comprehensive examination” that are no longer in place.

The investigators received no outside funding for their study. Ney reported receiving consulting fees from Ceribell Inc., a device maker, whereas a study co-author reported receiving consulting fees from Integra and Novo Nordisk and holding stock in other life sciences companies. Józefowicz reported no financial conflicts of interest.

Jennie Smith is a freelance science writer.