The farther you get from residency, the easier it is to rely on technology to make your clinical decisions. Asthma dyspnea or shortness of breath? Just get a chest xray. Cardiac murmur? Just get an echo. I once had a cardiologist tell me that they don't bother to differentiate cardiac murmurs anymore when an echo will be done anyway. Abdominal pain or confusion? Just order a CT (despite CT scan radiation exposure concerns) and you'll have your result in no time.
In many regards, the physical exam has gone by the way side. I can do a full physical exam covering all body organs that Medicare requires to bill a high level admit (CPT 99221, 99222, 99223) or consult (CPT 99253, 99254, 99255) in under five minutes flat. I know exactly what I'm looking for and what I'm not. I focus my attention on those parts of the exam that may require a heightened sense of awareness. Since I don't just order an echo on everyone.
On many patients, day after day, the physical exam is a waste of time. Because their condition and my management decisions are not affected by my physical exam findings. It doesn't matter what the lungs sound like in a pneumonia patient if their supplemental O2 needs are zero. But every now and then, the physical exam will make you earn your keep. I recently had one of those situations.
It was a busy day. I think it was around 6 pm. I had just finished seeing my 19th encounter for the day. It was also my first break of the day. And the phone rings. On the other end was the psychiatrist. It wasn't a consult per say. They just wanted to run something by me. You see, what the psychiatrist had in her possession was an elderly female she had admitted the night before directly from home with a diagnosis of depression. This nice old lady was losing weight and failing to thrive and the outpatient primary medical doctor was concerned. He had started her on outpatient therapy for depression, but the side effects were worse than the disease. And he needed help. And the psychiatrist agreed to admit her for further evaluation.
So why was I getting called? The psychiatrist was concerned about some laboratory findings that didn't make sense. A hemoglobin of nine, elevated liver tests and now fever. At this point, the first words out of my mouth were
"Doc, that sounds like a consult."
This is one case where the medical necessity of the consult is blatantly obvious. The psychiatrist said thanks. I said thanks and I trotted off to find the patient.
She was a wonderful lady. Healthy by old lady standards (at least for hospitalist medicine). She never smoked. Never drank. Had great looking skin. She looked like she took care of herself. But she was losing a lot of weight. Almost 60 pounds in the last year. For all you non doctor types out there that's what we docs call a red flag symptom. In a country where people swear up and down they gain weight while drinking Slim Fast and running six miles a day, it's nearly impossible to lose 60#s while trying, let alone not trying.
Beside the weight loss, she really had no complaints at all. Every single question I asked she answered no. That doesn't leave me much to go off of. Then came the physical exam.
And wouldn't you know, everything was normal. Like so many patients before me, the physical exam was a mix of observation and speculation. I couldn't find anything wrong. Perhaps there wasn't anything wrong. Or perhaps my physical exam skills have been trashed by my ability as a physician to order unGodly amounts of radiation exposure on you, the patient.
And then, there it was. An honest to God physical exam finding that I suspected, but wasn't expecting. What she had was bilateral inguinal lymphadenopathy (enlarged lymph nodes). They were large enough to make first year medical students salivate.
At this point I knew exactly what she had. A thin, elderly appearing lady losing a ton of weight presenting with anorexia, major weight loss, fever, anemia and adenopathy. She had lymphoma (possibly infiltrative to her liver and bone marrow) until proven otherwise.
At this point I made the decision to transfer her out of the psychiatric wing and into the medical floor for further evaluation. She didn't have life threatening depression. She had life threatening lymphoma.
What did I learn about this experience? That we as physicians should never take the physical exam for granted. I know it's easy to just order that xray or CT scan. Every doctor is guilty of this volume driven mentality where time is money. But often times, if we could spend time doing the cheapest part of the evaluation, taking a good history and performing a good physical exam, the answer could stare us right in the face.
In my elderly patient's case, she had been seen by her primary medical doctor, an ED physician, a hospitalist (just a couple weeks prior) and a psychiatrist, and every one of them missed the inguinal adenopathy. In the mean time she was placed on antidepressants, moved to a psychiatry floor and bounced from ER to clinic to psychiatry hospital to medical hospital. By now, her physicians have spent thousands of dollars from the Medicare National Bank.
Now she's in the medical hospital. Courtesy of me. A place she probably should have been in the beginning. In the the world of fee for service economics, courtesy of the third party vault of unlimited cash, every encounter from every one of her docs will get paid. And they will get paid the same whether they made the diagnosis or not. The hospitalist and ED doctors who saw her first will get paid. Her primary MD will get paid. The psychiatrist will get paid. The hospital will get paid not only for the ED evaluation, but also for the brief stay in the psychiatry wing and the inpatient DRG. Even the pharmacy and the pharmacists that dispensed the antidepressant will get paid.
Everyone will get paid. Thousands of dollars was spent by the Medicare National Bank on a patient bounced around for a diagnosis that could have been made had anyone of those doctors before me bothered to examine her lymph nodes.
So how do I get rewarded for my skills? I get a great personal satisfaction knowing I made the diagnosis. But financially? I would have received the same amount of money for my consultation had I not bothered to feel her groin for enlarged nodes. Had I followed the footprints of all docs before me and let her be. I would have received the same compensation had I come to the conclusion that she just had a virus and wasn't feeling well. I would have received the same compensation if I said anything or nothing at all, even if I was too busy to bother feeling her lymph nodes. Even if I was too busy not to pause and contemplate the 60# weight lose, anemia and fever. Even if I was too busy to care, I would have been paid the same.
As a tax payer, a health insurance premium payer and a future patient for sure, I want to know why I should be held responsible paying for the care provided by others who are either ignorant, lazy, fearful or greedy for the care they provide.
If I take the time to make the diagnosis, use my skills in the most cost effecting and efficient way I know how, I should be rewarded for my efforts. Everyone around this lady got paid by you, the tax payer. You should be mad as Hell. Until we change the way we deliver care in this country, I don't expect anything to change.
