Yes HANS DUVEFELT
Left to my devices, I will be selective about when and how much of a physical exam I do: either not at all or very detailed for just those things that can help me make the diagnosis. I have no patience for normal boilerplate tests. Any doctor who adopts the term PERRLA (equal, round, light-responsive and scalable scissors) is likely to falsify it. First, most of the time this isn’t really fully tested and second, even if it’s done right, it has no relevance in most of the paper notes I’ve found. I’ve actually seen it in office note templates for urinary tract infections!
It is well known that history makes the diagnosis in the vast majority of cases. But this task – or art, in fact – is sometimes relegated to supporting staff or forced into unnatural click boxes. Because reimbursement until recently was related to how many items were requested and examined, there was a loss of the patient’s illness history, or narrative. And you can get more brownie points by including things that were extremely peripheral to the clinical problem at hand.
EMRs make it easier to produce long office notes with high reimbursement and quality score points of uncertain clinical value and accuracy.
In particular, physical examination has become in many cases a corrupt, fraudulent, one-click disguise of art and professionalism that we swear to keep high when we graduate from medical school.
The pandemic and the rush towards telemedicine have made it clear to most people that medical diagnosis, counseling and treatment are entirely possible without physical contact. It was just a matter of getting paid for it, or the healthcare industry would stop, or at least a crawl.
Now that we have admitted that listening, talking, and a certain amount of watching or observing can be done without being in the same room, it is time for us to be honest about the value of the physical exam.
Our medical education in universities and tertiary medical centers has taught us to manage complex and confusing cases that had eluded diagnosis in the primary setting: Start from scratch, assume nothing. This is a method we need to use in selected clinical situations.
But in everyday practice that is inefficient and useless. Most of what we see is simple stuff and part of our job is triage, to know when something seemingly ordinary is or has the potential to be more serious.
We need to know how to do a really good and relevant physical exam when the situation requires it. But we also need to know when that will add nothing and just waste our time and effort.
We embrace the new honesty about the value of our work:
Our work cannot always be measured by its completeness or by the time it takes. The essays that people have looked for throughout human history tend to be brief and to the point, which is part of why they have always been valued. They see the central question more clearly. So should we as doctors. We need to know where to spend our effort.
The practice of medicine is a cognitive work. The more skilled they are, the less they may need to turn around to make a diagnosis. The better explained and motivated you are, the less time you will need to start a treatment plan for each patient.
Televisions tend to take less time than in-person visits. Considerations and implications of this in this era of alleged medical deficiencies. It is part of the basic question: Where is our best training and experience spent, performing ritual and pseudo-complete exams or clearing where attention is needed?
It does not support telemedicine on in-person visits. Telemedicine can be convenient and practical, especially when you live hundreds of miles away from specialists. But supporting a different view of clinic visit in general:
Stop falsifying completeness. Have the courage and integrity to do only what the clinical situation requires. Do not fill your visit or office notes with fake fur. If you then have the remaining time, use it to refer to your patient as a human, instead of a virtual / human checklist.
Hans Duvefelt is a Swedish-born rural family physician in Maine. This post initially appeared on his blog, A Country Doctor Writes, here.