Hospital Medicine: Out of Order

Physicans in Reverse Gear!

Here is some inside dope on the medical profession for patients to ponder.

We are all reading these days about improving the process of delivering medical care. This effort aims to raise the level of medical quality, and to minimize errors of omission and commission. This is why all surgeries and medical procedures begin with a ‘time out’, when there is a brief huddle confirming the identity of the patient and the intended operation. This is to prevent scenarios, such as:

“Mr. Patella, we replaced the wrong knee, but you would have needed a new one at some point. No need to get out of joint over this – the rehab is on us.”

Numerous medical specialties are now using checklists for medical procedures that include a series of steps. For example, if every heart bypass patient needs to proceed through 24 pre-operative steps, including laboratory studies, diagnostic tests, specialty consultations and an informed consent discussion, then a checklist is an effective tool to ensure compliance. Indeed, without a tracking mechanism, it is easy to understand how important steps can be omitted, with serious consequences. Chec-lists have been standard operating procedure in the airline industry, which have an excellent safety record.

Of course, there is a risk that physicians will become numb to all of these warnings and ‘time outs’. How carefully, for example, do we listen to flight attendants’ warnings and instructions prior to take-off?

This issue is relevant to how we physicians approach hospital patients. Here’s how we were taught to do it by our professors and mentors. See the patient first. Take the medical history personally, before you review the results of the CAT scan and other diagnostic tests. After taking the history directly from the patient, proceed with a methodical physical examination, which may provide important diagnostic clues. A medical condition that was considered probable after the history may be rendered unlikely after the examination. Additionally, an unexpected abnormality found on the physical examination, may lead the physician to pursue a different line of questioning that was not considered initially. After these two fundamental steps, the H & P, have been completed, the physician creates a differential diagnosis, a list of reasonable diagnostic considerations that can explain the patient’s condition. The doctor does not need to consider every diagnostic possibility, only those that are reasonable. For example, if you were to search diagnoses such as abdominal pain or fatigue on the internet, you could create lists that contain over a hundred entries. Sometimes, our patients bring us these lists convinced that their symptoms are explained by an obscure parasite, not present in this country, because the parasitic disease description matches the patient’s symptoms exactly.Obviously, physicians will expand the list of diagnostic possibilities, if the working list proves to be inadequate.

At this point, additional medical data are reviewed or tests are ordered to narrow the list, hopefully down to the correct diagnosis. Sometimes, the H & P is sufficient to make a reasonable diagnosis, and no further tests are required. For example, a patient who sees me with 6 weeks of heartburn that is consistently relieved with antacids doesn’t need to swallow my scope to make the diagnosis. I already know it, or I should.

This is how we were taught to see patients. Here's how it's done in the real world, particularly in the hospital. Every day, we physicians commit medical heresy, by seeing the patient last, after x-ray results, labs and specialist consultations are reviewed. I know this is true because I am one of these medical heretics. It is standard practice today to do what our medical school faculty beseeched us to avoid - seeing the x-rays before seeing the patient. Nowadays, when physicians enter patients’ rooms, we often already know that the CAT scan shows diverticulitis, or that there is a kidney stone, or that a cardiac stress test is abnormal.

What is wrong with this? Don’t physicians still get to the right answer, even if today’s diagnostic path is reversed?

I am hostile to this approach, which I practice, because it devalues the history and physical examination, which is the core of doctoring. When the physician greets a patient, and already believes that he knows the diagnosis, then the H & P became a diagnostic afterthought, a formality that must be performed more for documentation than for diagnosis. This means that the doctor will not take a broad and probing history, as he no longer feels the need to construct the classic differential diagnostic list. If the doctor meets a patient after viewing a CAT scan suspicious of appendicitis, he may take a cursory history and miss the correct diagnosis, which may not require surgery. It is in patients’ interest for physicians to think broadly at the outset, narrowing down the possibilities over time. It is harder to reverse this process. Once a patient is labeled with a diagnosis, it can be difficult to peel it off. This is why diagnostic labels should not be affixed prematurely. Seeing the patient out-of-order risks this outcome.

Internist to gastroenterologist: "Please see my patient, Mr. Calculus, in room 304 with vomiting. This is his 3rd gallbladder (GB) attack in 6 weeks.

This patient has now been labeled with GB disease.Will the gastroenterologist be open-minded enough to take a full history? Will he discover, for example that this patient ‘borrowed’ pain pills from a friend to relieve his back discomfor? Perhaps, his symptoms are a side-effect of these medicines. If so, then removing the gallbladder is the wrong move.

The out-of-order approach also has eroded physicians’ physical examination skills. If I already know from viewing a CAT scan that a patient has an enlarged spleen, then I will be biased when I palpate the abdomen at the bedside. Sure, I might feel the spleen, but will I examine the rest of the patient with necessary diligence? What if the spleen is not the critical finding? Physicians who examine hearts, lungs and abdomens – when they already know of abnormalities in advance – cannot be fully objective.

Finally, the out-of-order strategy reinforces to patients and the medical profession that testing and technology are more important than the initial human interaction with hands-on contact. This is not true, and yet this is increasingly the way of the medical world.

I maintain the medical history is the most valuable diagnostic took that exists, and it is at risk of being included on the endangered species list. Beyond its medical value, it is a foundation of the doctor-patient relationship, which is already under threat on so many fronts.
Here’s the checklist I wish I used without exception:

___ History
___ Physical
___ Other Stuff


Why do doctors like me who know that the H & P should come first, use the reverse gear istead?  The response to this question should be of great interest to the public, and I hope that this inside dope will appear below in the comments section.   OK, physicians, come clean.