Online Symptom Checker (Funny WebMD FAIL).

One of the benefits of admitting a 90 year old demented patient to the hospital is documenting unobtainable review of systems  due to baseline dementia. This is allowed under the published CMS evaluation and management (E/M) rules.  This documentation will qualify the ROS component for the highest level of  care associated with that patient's evaluation.    It's actually quite silly.  That whole idea of paying a physician based on how many predefined questions they ask.  In theory, asking all these silly questions every time  will always be medically necessary because you don't know if the questions have relevance until after the questions have been asked.  In practice, it's a waste of time and physicians ask questions based on their style of interview as well as back and forth give and take communication between patient and doctor.  

A list of questions called the review of systems is worthless, except in the eyes of payers who define effort and therefor payment based on ROS documentation.  As a hospitalist in the field for almost a decade,  I can tell you that the complete review of systems will always be medically necessary, but often irrelevant.  The same goes for the complete physical exam.  Always medically necessary, often irrelevant.  But these are the rules we have been given.  Pay me to care for patients the way I think is best, not the way payers thinks is worth it and I could double or triple the number of patients I see in a day without any loss of quality. 

Taking histories and doing physicals is what all physicians have been trained to do.   Thoroughness defines our practice as physicians.  We ask questions in search of answers.  We examine in search of a diagnosis.  Telling us what's important and what we need to document in order to get paid isn't.  If that isn't the most inefficient distraction to the delivery of efficient, high quality medical care, then I don't know what is.   A review of systems is  really not all that helpful in the clinical course of how physicians do their patient evaluations.  That might come as a shocker to new medical students brainwashed by their attending physicians with their three hour, six page evaluations  with no plan, on their first day of internal medicine, but it's readily apparent by the time you're trying to decide on your 4th year rotations to take in medical school.  It's time for the review of systems to die a quick death.  I am not a fan by any means.  The review of systems process is nothing more than a generation of  mostly worthless information that no one reads.  It has limited bearing in how we work through our differential diagnosis.  I presume the whole ROS process was created as a way to implement defined payment structures for E/M notes.  Documenting the ROS is really a documentation headache of magnificent proportions.  

Now that I've established the complete idiocy of our review of systems process and how obstructive it is to our normal work flow in the course of daily patient care, I'd like to present to you how these online symptom checkers are taking the ROS to new unbelievable heights.  Instead of accepting the process as nothing more than a miserable attempt to quantify effort, they have taken the ROS  to the next level of absurdity.  Here's an example of how WebMD's online symptom checker has shown, in true form, how absurd the ROS has become.   I suppose it's only a  matter of time before CMS starts accusing physicians of fraud for not documenting a patient's trembling associated with cannibalism in Papua New Guinea in their complete review of systems.  Because we all know how warped these Medicare fraud statistics really are. 

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