I remember very clearly as a medical student hearing my attending hammer home the importance of the history and physical. Everyday I heard the same thing: The history and physical examination is the most important part of patient care. After seven long years of hospitalist medicine, I gotta say my attendings were right. If you listen to what the patient is telling you, the answer is often staring you in the face. Unfortunately, in this volume driven world of fee for service we live in, time is not on the physician's side. Most elderly patients are incapable of separating important medical information from irrelevant medical information, which can make history taking a very painful part of being a doctor. So they just talk and talk and talk.
We are always taught to open up the conversation with open ended questions. I hate to say it but a lot of open ended patient history is complete jibberish. With that said, I find that most patients will still give you the answer you're looking for if you simply take the time to listen. It's the physician's job to tweak it out. My favorite question to ask a patient when I walk into the room is "What's goin' on?" How they respond says volumes about their disease process.
How about a comprehensive physical examination? It too can add important diagnostic information for physicians developing the therapeutic plan. Whether the complete physical examination makes the diagnosis or simply corrects a wrong assumption, laying eyes on the patient will always play an important role in patient care. And even Happy isn't perfect. I'm sorry to report that I once broke my own rules:
Nurse: We have a consult for you. It's a psychiatric patient with knee pain.
Happy: Did they fall?
Nurse: Um, yes, I think several weeks ago
Happy: Will you get an xray of the knee?
Nurse: Will do.
After finishing up three more admissions, I hunted down the radiologist and reviewed the knee film. Normal. Then I went to talk to the patient.
Happy: What's goin on Mrs Smith?Mrs Smith: My knee hurts.Happy: looking at knee Your knee looks fine. It's moving fine and your xray is normal. I don't think there is anything to do about it.Mrs Smith: You mean there are no bugs in there?Happy: No Mrs Smith, there are no bugs in your knee.
One golden rule of medicine is never to assume anything. I suppose if I had taken the time to talk to the patient before I ordered the xray I could have saved $200 in facility fees and professional fees from the Medicaid National Bank. Instead I have no skin in the game and someone else pays for it. Perhaps in an effort to be efficient with my time, I wasted many others. Stop right there doctor. The history and physical examination really is the most important part of the evaluation. I suppose someday when bundled care arrives, these kinds of convenience xrays will disappear as the money gets tighter and the incentive to practice competent and efficient care prevails.