Old school

A recent post at db’s medical rants addressed the question of whether or not the skills of history taking and physical exam have declined in recent years, and he asked the question ‘What does old school mean to you?

To me ‘old school’ means taking a good history and then performing a focused physical exam. So what exactly does this entail?

History:

Old school:

Questions are asked regarding the patients known medical conditions and the problem at hand. Relevant information is discussed, often but not always including some details about the patient’s occupation and family. If I am sewing up a laceration on someone’s leg from a chainsaw accident, I don’t need a family history, (but I might want to ask if any substances were involved). Treating a swimmer’s ear does not require much history at all, unless this is a recurrent problem or unusual presentation. On the other hand, a patient presenting with heart failure may need an hour’s worth of history, exploring other medical problems, current and past occupations, extensive family history, living conditions, and any history of substance abuse. The history adapts to the situation. I personally do not take notes or use a computer when taking a history – talking with the patient and looking them in the eyes

Modern reality:

In order to bill for the visit you need to make sure that you have checked enough items under the history of present illness, that the past medical history is documented, a social history is documented, a family history is documented, and an extensive review of systems is documented. Most of this is clerical data entry and is done by nurses or medical assistants. If you are very efficient you can click through the boxes to get a level 4 visit paid in a few minutes.

Physical exam:

Old school:

Hands on exam including (for me) listening to the heart and lungs of every patient, and then a focused exam regarding the issues that need to be addressed. In patients with diabetes or hypertension, a (gasp!) fundoscopic exam can be very useful. Looking at a patient’s hands can provide an encyclopedia’s worth of information. When patients complain of gout we actually have them take off their shoes and socks and (double gasp!) touch their feet.

Modern reality:

Too many doctors do not even examine the patient. They look at the electronic health record and click off the boxes. The entire physical exam section of the clinical note is boilerplate to fulfill billing rules. Patients tell me that they have seen doctors who did not examine them at all but stood by the door and diagnosed them based on what was in the computer. Some doctors seem to think that their patients are ‘icky’ and do not want to touch.

The problem of modern medicine

The problem today is a mentality that the history is all you need and then technology – lab tests and imaging – will make the diagnosis clear. This mentality has been driven by a number of forces. The most important force that drives everything in medicine is money. The way doctors are paid is insane. Take, for example, a challenging patient with a rare medical condition seen by two different doctors:

Doctor #1

Doctor #1 was the top of their class, well educated, sharp, engaged, and takes time to do a thorough history and physical exam on the patient. The doctor comes up with a presumptive diagnosis and sends a lab test to confirm or exclude the condition. After one hour, doctor #1 bills for 1 level 5 visit and a lab test. The insurance company refuses to authorize the lab test because it is for a rare condition and the bean-counter there has never heard of this test. They also question whether doctor #1 is billing too many level 5 visits. The patient then gets a huge bill from the lab company and makes an angry phone call to the doctor. The doctor’s practice goes broke and he burns out.

Doctor #2

Doctor #2 was at the bottom of their class and has no clue as to what could be wrong with the patient. He spends five minutes with the patient, orders 100 lab tests, and refers the patient to a specialist. He then goes on and treats eleven other patients that hour in the same way. After one hour, doctor #2 bills for twelve level 4 patient visits, 1200 lab tests, and laughs all the way to the bank.

 

Which doctor do you want? Doctor #2 may be just fine if you have pink-eye or a stubbed toe, but what if you have amyloidosis and need a heart transplant? Why does the system favor doctor #2 so much?

 

Old school

You must put hands on the patient. There is a tremendous amount of information that is gathered by simply listening to the heart and lungs. Patients often do not tell everything up front. You can take a history that you think was complete and all of a sudden you see a scar and ask about it. A patient will then spill out ‘Oh I had heart surgery as a kid’ or something similar. (it would have been helpful if they had mentioned it before)

Check-boxes and past medical history forms are not sufficient to obtain a medical history –they are only tools to get paid.

What ‘old school’ seems to mean is actually being a doctor. Taking time with patients, touching patients, and examining them is essential to medicine.

Some doctors think that it is OK to not learn about different heart murmurs – just get an echo. What a waste of resources! This is why medical care is so expensive. Yes, an echo can tell you more about the heart, but the way the medical system is now this requires time, money, and lots and lots of paperwork – er, computer data entry.

If we were paid a salary as doctors instead of fee-for-service everything would be much easier. Then we could use echo machines for diagnosis and not worry about what billing code we need to use and making sure that we have a complete study. If our payment system were different we would all be using mini echo devices just as we (well, at least some of us) use a stethoscope today.

This is why doctors switch to concierge practices. Unfortunately this is not an option for most specialists.

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