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Like most physicians, I feel extremely rushed during the course of my work day. And every day I am tempted to cut corners to get my documentation done. The “if you didn’t document it, it didn’t happen” mantra has been beaten into us, and we have become enslaved to the quantitative. It’s tempting to rush through physical exams, assuming that if there’s anything “really bad” going on with the patient, some lab test or imaging study will eventually uncover it. Just swoop in, listen to the anterior chest wall, ask if there’s any new pain, and dash off to the next hospital bed. Then we construct a 5-page progress note in the EMR, describing the encounter, our assessment, and plan of care.
Focused physical exams have their place in follow up care, but I strongly urge us all to reconsider skimping on our exams. A fine-toothed comb should be used in any first-time meeting – because so much can be missed as we scurry about. Some examples of things I discovered during careful examination:
1. A pulsatile abdominal mass in a woman being worked up for dizziness.
2. New slurred speech in an edentulous gentleman with poorly controlled hypertension.
3. A stump abscess in a 2-year-old leg amputation.
4. A bullet lodged in the scrotum.
5. Countless stage 1 sacral decubitus and heel ulcers.
7. Rashes that were bothering the patient for years but had not previously been addressed and cured.
8. Early cellulitis from IV site.
9. Deep venous thrombosis of the calf.
10. New onset atrial fibrillation.
13. Peripheral neuropathies of various kinds.
14. Lateral medullary syndrome.
15. Surgical scars of all stripes – indicating previous pathology and missing organs of varying importance.
16. Normal pressure hydrocephalus in a patient who had been operated on for spinal stenosis/scoliosis.
17. Parkinson’s Disease in a patient with a fractured hip.
18. Shingles in a person with eye pain.
19. Aortic stenosis in a woman with dizziness.
20. Pleural effusions in a man complaining of anxiety.
Oftentimes I don’t find anything new and exciting that is not already a part of the patient’s medical record. But a curious thing happened to me the other day that made me reflect on the importance of the physical exam. After a careful review of a complex patient’s history, I discussed every scar and “abnormality” I discovered as I did a thorough head-to-toe review of his physical presentation. His aging body revealed more than he had remembered to say… and as our exam drew to a close, he reached out and offered me a fist-bump.
It was charming and unexpected – but made me realize the true importance of the thorough exam. I had gotten to know him in the process, I had earned his trust, and we had built the kind of therapeutic relationship upon which good healthcare is based. No EMR documentation effort was worth missing out on this interaction.
You may not uncover a new diagnosis on each physical exam, but you can gain something just as important. The confidence and respect of the patient.
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Popular TV doctor, Gregory House’s favorite adage about patients is: “everybody lies.” I used to believe that this was a cynical and inaccurate statement, but I had to revisit it recently when faced with a patient whose signs and symptoms were consistent with a diagnosis that she vehemently denied.
A young woman was admitted to my rehab unit with brain damage of unclear cause. She adamantly denied drug or alcohol use, and I couldn’t help but wonder if she was suffering from a genetic or autoimmune disorder that the academic neurology team had somehow overlooked. I had recently read the New York Times best-seller, Brain on Fire and feared that I would be like one of those dismissive physicians who missed the author’s unusual diagnosis and nearly killed her from their inaction.
But staring me in the face were the specific physical manifestations of drug and alcohol abuse, though her urine toxicology screen proved she hadn’t used in the very recent past. I asked her again and again if she recalled any exposure to them – probing for an admission of even a small amount of recreational use. She remained adamant. An exhaustive work up had in fact revealed some vitamin deficiencies, the only hard evidence of anything that could explain her very real and devastating impairments. This was not a case of faking symptoms – at least I was sure of that much. Yet her situation continued to haunt me, because until she came clean about the cause of her condition, lingering doubt would drive me to continue the “million dollar work up.”
And for this young and desperately lonely person, the “million dollar work up” may have been her only chance at experiencing ongoing concern for her well being from others. If she admitted to drug use, then the only people who seemed to care about her (sadly, even if it was mostly because she could make a “great case for Grand Rounds”) would probably turn their backs. With the mystery solved, this fascinating neurological conundrum would become a garden variety drug abuser. A person who was, perhaps, not so much a victim as a perpetrator of their own condition.
I don’t believe that those whose conditions are contributed to by their behaviors receive poorer medical care (consider the smoker with lung cancer, or the person with multiple fractures from a bridge-jump suicide attempt – their quality of care will be similar to non-smokers with lung cancer or people with orthopedic needs from a motor vehicle accident). But there may be a subtle and unspoken judgmental attitude held by some of their caregivers and providers.
Fellow friend and blogger, Kerri Morrone Sparling suggests that fear of judgment, and the guilt and shame associated with self-induced harm, are the main reasons why people with diabetes may not come clean to their endocrinologists about their eating and exercise habits. She writes,
Finding enough confidence in myself to admit my shortcomings to my doctor, who I aim to impress with my efforts, was a tall order. For me, it took finding an endocrinologist I trusted with the truth, including the parts of the truth that weren’t so pretty. I know the best doctor for me is one who cares about my emotional response to diabetes, as well as my physical response. It took some trial-and-error, but eventually I found an endo who I felt didn’t judge, but listened and helped me find reasonable solutions to my problems with “reasonable” defined as something I would actually follow through on. Instead of a blanket response of “Do everything. Try harder,” my endo helps me build off of small successes in pursuit of better outcomes.
So patients lie to their doctors because they don’t want to be abandoned, judged, or shamed. And until they are quite certain that this will not happen to them, they are likely to continue withholding information from those who are ostensibly trying to help. The problem of lying does not rest squarely on the shoulders of patients – it is also the responsibility of physicians to make it safe for them to tell the truth. They will commit to honesty when we commit to compassion.
As I look back at my interactions with the young woman with the “mystery” illness, it is not so much the fear of missing the right diagnosis that haunts me now. It is that I did not make her feel safe enough to tell me the truth. In the end, the “million dollar work up” offered her little value for the cost and used up precious healthcare resources.
What she needed was a safe place to live, a supportive environment, a program for drug counseling, and job training for those with disabilities. I missed out on really helping this patient because I was more comfortable with searching for a rare diagnosis than pursuing treatment for the all-too-common, nebulous cycle of social ills that poverty, drugs and abuse cause. Maybe I wanted to believe her lie because at least then there was a chance I could fix her?
As it turns out, I was as invested in her lie as she was – we just had different reasons for it. While she did not want to be abandoned or shamed, I did not want to have to face the fact that I had very little to offer her.
Dr. House was right – under certain circumstances, patients are likely to lie. The other side of the coin, though rarely discussed, is that sometimes doctors are complicit in keeping those lies going.
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Many of the patients that I treat have brain injuries. Whether caused by a stroke, car accident, fall, or drug overdose, their rehab course has taught me one thing: nobody likes to be forced to do things against their will. Even the most devastated brains seem to remain dimly aware of their loss of independence and buck against it. Sadly, the hospital environment is designed for staff convenience, not patient autonomy.
In the course of one of my recent days, I witnessed a few patient-staff exchanges that sent me a clear message. First was a young man with a severe brain injury who was admitted from an outside hospital. EMS had placed him in a straight jacket to control his behavior on his trip and by the time I met him, he was in a total panic. Sweating, thrashing, at risk for self harm. He didn’t have the ability to understand fully what was happening but one thing he knew – he was being restrained against his will. The staff rushed to give him a large dose of intramuscular Ativan, but I had a feeling that he would calm down naturally if we got him into a quiet room with dim lights and a mattress with wall padding set up on the floor. As it turned out, the environmental intervention was much more successful than the medicine. Within minutes of being freed to move as he liked, he stopped moving much at all.
Later I was speaking with one of my patients in the shared dining room. An aide arrived with a terry cloth bib to tie around his neck so that he didn’t spill anything during lunch. I saw a flash of anger in my patient’s eyes as he pulled the bib away from his neck with his good arm and placed the towel on his lap instead. I could tell that he found the bib infantalizing, though none of us had thought twice about it before. Here again, a patient did not appreciate having everything determined for him, right down to napkin placement.
Towards the end of the day, I was bidding farewell to a patient whose care would be provided by another attending physician going forward. I was summarizing my view of his progress and expectations for the future, and stopped to ask if he had any questions. What he asked completely flummoxed me. Instead of probing for details about his medical condition and treatment options, he asked, “Will the new doctor be a good listener? Will she pay attention to what I’m saying and be easy to talk to?”
It is unfortunate that healthcare providers and patients are often on very different wavelengths. In Atul Gawande’s recent book, Being Mortal, he argues that nursing homes have often failed to provide healthy environments for patients because they have focused exclusively on safety and meeting basic needs (eating, dressing, bathing, etc.) on their terms. The removal of patient independence unwittingly results in devastating loneliness, helplessness, and depression. It seems to me that hospitals end up doing the same thing to patients – if only for a shorter period of time.
I was moved by Gawande’s book (and I consider it required reading for anyone facing a life-limiting illness or caring for someone who is). It renewed my conviction about the importance of rehabilitation – helping people to become as functionally independent as possible after a devastating injury or disease. Even as we age, we all become less able to do the things we hold dear. Preserving dignity by prolonging independence, and respecting patient autonomy, are often overlooked goals of good health care. It’s time to think about what our actions – even as small as placing a bib around someone’s neck – are doing to our patients’ morale. Maybe it starts with asking the right questions… Or better yet, just watching and listening.
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In my last blog post I discussed how harmful physician “thought leaders” can be when they are dismissive of the value of other specialists’ care. I must have touched a nerve, because a passionate discussion followed in the comments section. It seems that physicians (who spend most of their time involved in clinical work) are growing tired of the leadership decisions of those who engage in little to no patient care. Clinicians urge lawmakers to turn to practicing physicians for counsel, because those who are out of touch with patients lack real credibility as advisers.
Interestingly, the credibility question was raised in a different light when I was recently contacted by a prestigious medical organization that was seeking expansion of its board membership. I presumed that this was a personal invitation to join the cause, but soon realized that the caller wanted to use my influence to locate “more credible” candidates with academic gravitas.
When I asked what sort of candidate they wanted my help to find, the response was:
“A physician with an academic appointment at a name brand medical school. Someone who isn’t crazy – you know, they have to be respected by their peers. Someone at Harvard or Columbia would be great. You must know someone from your training program at least.”
While I appreciated the honesty, I began thinking about the age-old “town versus gown” hostilities inspired by academic elitism. In medicine, as with many other professions, it is more prestigious to hold an academic position than to serve in a rural community. But why do we insist on equating credibility with academics?
Another facet of credibility lies in physicians’ tendencies to admire only those at the top of their specific specialty. Dr. Lucy Hornstein described this phenomenon in her powerful essay on “How To Drive Doctors To Suicide:”
“Practice that condescending look and use it at hospital staff events. Make it a point to ignore newcomers. Concentrate on talking just with your friends and laughing at inside jokes, especially when others are around. Don’t return their calls, and don’t take their calls if you can possibly help it. If you accidentally wind up on the phone with the patient’s primary physician, just tell them you’ve got it all under control, and that he (and the patient) are so lucky you got involved when you did.”
A reader notes:
“And perhaps those of us who do see patients should get some self esteem and stop fawning all over [physician thought leaders] at conferences like needy interns.”
And finally, there seems to be an unspoken pecking order among physicians regarding the relative prestige of various specialties. How this order came about must be fairly complicated, as dermatology and neurosurgery seem to by vying for top spots these days. I find the juxtaposition almost amusing. Nevertheless, it’s common to find physicians in the more popular specialties looking down upon the worker bees (e.g. hospitalists and family physicians) and oddballs (e.g. physiatrists and pathologists).
While I try very hard not to take offense at my peers’ dismissiveness of my career’s value, it becomes much more concerning when funding follows prejudicial lines in the medical hierarchy. As a sympathetic family physician writes:
“I have observed the inequitable distribution of resources from the less glamorous to the sexy sub specialties despite obvious patient needs. Unfortunately, the administridiots who usually lack any medical training, opt to place resources where they are most likely to attract headlines.”
Yes, caring for the disabled (PM&R) is “less glamorous” than wielding a colonoscope (GI) (again, not sure who made that decision?) but it should not be less credible, or become a target for budget cuts simply because people aren’t informed about how rehab works.
It is time to stop specialty prejudice and honor those who demonstrate passion for patients, regardless of which patient population, body part, or organ system they serve. Excellent patient care may be provided by academics, generalists, or specialists, by those who practice in rural areas or in urban centers. The best “thought leaders” are those who bring unity and an attitude of peer respect to the medical profession. With more of them, we may yet save ourselves from mutually assured destruction.
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Electronic medical records (EMRs) now play a part in the daily documentation routine for most physicians. While improvements in access to patient data, legibility of notes, and ease of order entry are welcome enhancements, there is a significant downside to EMRs as well. Although I’ve blogged about my frustrations with nonsensical, auto-populated notes and error carry-forward, there is a more insidious problem with reliance on EMRs: digital dependency.
The idea of digital dependency first occurred to me during a conversation with a young medical resident at a hospital where we share patients. I was bemoaning the fact that I was being forced to use hospital-designed templates for admission notes, rather than a dictation system or carefully crafted note of my own choosing. She looked at me, wide-eyed and said:
“You’ve worked without templates? How do you even know where to begin? Can you really dictate an entire note off the top of your head? I couldn’t live without templates.”
As I stared back at her with an equal amount of bewilderment, I slowly realized that her thinking had been honed for drop-down menus and check boxes. Over time, she had lost the ability to construct narratives, create a cohesive case for her diagnostic impressions, and justify her patient plan of action. To this bright, highly trained mind, clinical reasoning was an exercise in multiple choice selection. Her brain had been optimized for the demands of an EMR template, and mine was a relic of the pre-EMR era. I was witnessing a fundamental cognitive shift in the way that medicine was practiced.
The problem with “drop-down medicine” is that the advantages of the human mind are muted in favor of data entry. Physicians in this model essentially provide little benefit over a computer algorithm. Intuition, clinical experience, sensory input (the smell of pseudomonas, the sound of pulmonary edema, the pulsatile mass of an aneurysm) are largely untapped. We lose our need for team communication because “refer to my EMR note” is the way of the future. Verbal sign-outs are a thing of the past it seems, as those caring for the same patient rely on their digital documentation to serve in place of human interaction.
My advice to the next generation of physicians is to limit your dependency on digital data. Like alcohol, a little is harmless or possibly healthy, but a lot can ruin you. Leverage the convenience of the EMR but do not let it take over your brain or your patient relationships. Pay attention to what your senses tell you during your physical exam, take a careful history, listen to family members, discuss diagnostic conundrums with your peers, and always take the time for verbal sign outs. Otherwise, what advantage do you provide to patients over a computer algorithm?
Am I a curmudgeon who is bristling against forward progress, or do I have a reasonable point? Judging from the fact that my young peers copy and paste my assessment and plans into their progress notes with impressive regularity, I’d say that templatized medicine still can’t hold a candle to thoughtful prose. Even the digitally dependent know this.