Death of the Art of Medicine: My Thoughts When I started practicing medicine in the 80’s and actually before that, in medical school, I was taught that the most important aspect of patient evaluation was the history given by the patient guided by our questions. If I asked the right questions, the patient would most likely give me the diagnosis before I started the physical exam or ordering tests. The physical exam and tests were used, not to rule in disease, as much as to rule diseases out. In medical school, I was taught that for any problem, the differential diagnoses could be up to 100 diseases. I was also taught that the top three were probably the most important. I’m sure we were all taught the old adage; “If you hear hoof beats look for horses, not zebras.” I was taught to investigate the top three possibilities and order tests appropriately to rule them in or rule them out. The first step after the history would be the physical exam; a patient comes in with a known history of atherosclerotic cardiovascular disease and has been having shortness of breath and edema for three days. The physical exam would probably have shown Ralls in the lungs, an elevated JVD, and edema. The most likely diagnosis at this point would be congestive heart failure. I would probably run further tests to confirm this with a chest x-ray and maybe even an EKG. With just a history and physical exam, treatment could be started while further evaluation was being done to see if the patient was going to need alterations in medications and treatment in the long term. Now when a patient comes in with a history of coronary vascular disease, shortness of breath, and edema, the patient immediately receives a chest x-ray, EKG, Echocardiogram, and BNP. A brief history is done which may or may not include the when, who, what, why, or where for the illness. Treatment is now initiated only after all the test results are evaluated. As a family practitioner, I was trained to take care of patients from birth to death. I still have multigenerational families as well as patients I have been taking care of for approximately 30 years. I realize that as I have gotten older my patients have also aged. In this day and age, I find that patients change primary care physicians (politically correct) approximately every two years because their work site changes insurance coverage. Just about the time I get to know the patient, they are forced to switch physicians. This is often due to the costs of insurance. This makes it difficult for good medical care. Although, l must admit that Beaver has made this easier because we accept most insurance plans. Technology is also part of the problem. Patients are constantly told by the media that there is a pill or treatment that will fix anything, and probably could have fixed it yesterday. One example is the patient that thinks an MRI can diagnose anything. How many of us have had a patient come in asking for an MRI? They state they just “feel ill.” They do not have any idea what an MRI is and can’t tell us which part of the body should have the MRI. Part of our job now is to explain to the patient why the stomach medicine advertised on TV will not fix their diarrhea because the ads do not mention it is for heartburn. We also have to explain to the patient why most fancy tests are not able to diagnose every problem possible. I was taught to explain to the patient why I was prescribing medication, what the medication was for, and what possible side effects might be associated with the medicine. We previously did not give the patient the full list of possible side effects, but did advise the patient that if there were any problems to call our office. We also explained why we were ordering tests, what the tests were for and what we expected to find. The cost of and regulations for new medications for pharmaceutical companies are additional problems. It used to be that new medications were sampled quite heavily. This way the patient could actually try the medication and we could find out if it helped or if the patient had side effects. This could be done without cost to the patient. Now, because of new regulations, we receive limited samples. Patients have to pay to try new medications which are often prohibitively expensive. Patients frequently cannot afford to pay $300 a month for one pill a day. An example that comes to mind is the new anticoagulants. They seem to be much better than Coumadin or Warfarin and do not require the patient to have frequent blood tests. Patients find out how much the medication costs, however, and since the Coumadin required blood tests do not cost them anything, they often stick with Coumadin. Also, because of regulations, the patient receives a 3 to 10 page handout of possible side effects, most of which occur less than 1% of the time. This makes it difficult for patients to take the medication because quote, “I do not want to get all of these side effects.” We have to explain to the patient that side effects happen rarely or infrequently, but they must watch for them. Most of my older patients will not take new medications because of the quote, “possible side effects.” (Just as an aside, we now do not get pens or Post-it notes with pharmaceutical companies’ names on them because this is considered bribery. I personally do not know a single physician who prescribed medication based on the pharmaceutical company name on the pen or notepad he was using.) Now, it is important to discuss electronic medical records (EMR). The use of electronic records was implemented to make coordination of care easier and more complete. The example I use is the patient of mine having chest pain in Podunk, Alaska. With electronic records, the emergency room could call and link to our computer, review records for this patient and compare EKGs, labs or other information. This is an excellent idea. The only problem is the multitude of electronic medical record programs available that cannot interface with each other. Hell (not politically correct), Beaver Medical cannot even link to hospitals ten miles away such as Kaiser, Loma Linda University Medical Center, St Bernadine’s Medical Center, or Arrowhead Regional Medical Center. (Dumb isn’t it?) Electronic medical records make the storage of data easy but retrieval and review are difficult and sometimes impossible. To review the last office notes for the assessment of a patient’s abdominal pain . . . click, look, click, look, click, look, click, look, click, look, click look. This does not even include the scrolling necessary to get to the bottom of the page for the assessment. This is my last comment on electronic medical records. I was taught that when I was talking to a patient (actually, to anyone), I was to face the patient, look at the patient, and do what was called “active listing.” Although I still try to do this, it is very difficult when I have to type things into the computer, find labs in the computer, go to other screens to look at past medical records, hospital records, or just to look at immunizations. This is probably one of the most disconcerting things to me because I feel I am not so much talking to my patients as I am entering or looking for data in the computer . Another lament is regarding Primary Care Health Care Providers (PCHCP) (politically correct for Family Practitioners) and our relationships to Specialists. It was the PCHCP’s job to evaluate and treat the patient’s medical problems. When, after a thorough evaluation and possibly treatment, if the patient was still having problems, the patient was then referred to a specialist. The specialist would actually answer questions without seeing the patient, educate us in the evaluation and treatment of information. This is an excellent idea. The only problem is the multitude of electronic medical record programs available that cannot interface with each other. Hell (not politically correct), Beaver Medical cannot even link to hospitals ten miles away such as Kaiser, Loma Linda University Medical Center, St Bernadine’s Medical Center, or Arrowhead Regional Medical Center. (Dumb isn’t it?) Electronic medical records make the storage of data easy but retrieval and review are difficult and sometimes impossible. To review the last office notes for the assessment of a patient’s abdominal pain . . . click, look, click, look, click, look, click, look, click, look, click look. This does not even include the scrolling necessary to get to the bottom of the page for the assessment. This is my last comment on electronic medical records. I was taught that when I was talking to a patient (actually, to anyone), I was to face the patient, look at the patient, and do what was called “active listing.” Although I still try to do this, it is very difficult when I have to type things into the computer, find labs in the computer, go to other screens to look at past medical records, hospital records, or just to look at immunizations. This is probably one of the most disconcerting things to me because I feel I am not so much talking to my patients as I am entering or looking for data in the computer nother lament is regarding Primary Care Health Care Providers (PCHCP) (politically correct for Family Practitioners) and our relationships to Specialists. It was the PCHCP’s job to evaluate and treat the patient’s medical problems. When, after a thorough evaluation and possibly treatment, if the patient was still having problems, the patient was then referred to a specialist. The specialist would actually answer questions without seeing the patient, educate us in the evaluation and treatment of hospital records, I have to click the icon for these programs and then enter my user ID and password. If I want to look at business emails, I must click on another icon and enter another password. If I wish to look at the Physician Report Portal, I click on another icon and enter another password. It is impossible to calculate the amount of time I spend just entering passwords and user IDs. Unfortunately, this is all time I will never get back in my life. I almost forgot, every time I go into an exam room to see a patient, I have to enter my user ID and password. This occurs approximately 20 times a day. Meanwhile, the patient gets to sit there and look at me while I wait for the computer to come alive. Another thought, I used to need only my California Medical License number and DEA number to identify me for anything I did in the medical field. I am not sure exactly how many numbers I have that identify me as a doctor, but I think it’s five. I still have my medical license number and DEA number which have remained mine since approximately 1980. Now, I also have a UPIN, a national medical ID number and an E-script number. Do not ask me what these last three numbers are, or why I need them . . . I have them written down someplace. I am sure that there are other numbers of which I am not aware. Forms are another area of big change. Thirty years ago, the most common form was a Department of Motor Vehicle (DMV) driver physical form. Physicians also had an occasional disability form, and off-work orders were written on prescription pads. We still have the DMV form, but now it is four pages long. The disability form is now also four pages long. If I get a disability form from a patient’s lawyer it is ten pages long. Also, now, the Family Medical Leave Act requires every physician to guess/estimate how many times a patient is going to be seen during the year and how many times they will need to miss work because of their illness . . . things for which any physician would need a crystal ball. I am just going to list some of the other forms that Primary Care Health Providers must complete: Off-work orders are now a letter. Prior authorizations for tests Prior authorizations for referrals to specialists Prior authorizations for tests that specialists are requesting Referral forms for specialists within our medical group and for health education I already mentioned prior authorizations for medications. I forgot to mention that occasionally, I will do the standard form for medication and receive a faxed form from the insurance company requesting the same information be transferred onto their form in order to be reviewed. Prior authorizations for darn near anything else that I think might be needed. I am sure the above list is not all-inclusive and that there are a multitude of forms I forgot to put on it, but after listing the ones above, my brain shut down. Excuse me now while I reboot, as soon as I remember my user ID and password Paul Whiteside,MD
Posted on: Tue, 10 Sep 2013 17:48:32 +0000
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