Kevin, M.D. - Medical Weblog

I have had it up to my eyeballs with colleagues who do not take histories and exam patients. In my own parents alone, it has resulted in many thousands of dollars in unnecessary procedures.

That examinng patients and taking histories is not reimbursed well is not an excuse. Wanting to make money is NOT and excuse for frankly unprofessional and unethical modes of practice. It is an excuse for not entering certain lines of clinical work but it is not an excuse for doing whatever work you do participate in like a slob and a quack.

Physician's above all people are expected to set high personal standards of performance and stick to them. When encountering a system of care that frustates the achievement of that standard, they are responsible for refusing to cooperate while agitating for change, or simply refusing to work in that system. Anything less is merely excuse for laziness, moral cowardice, or greed.
 

Holy cow! Please tell me where you work so I can avoid it. Last time I checked, all of my partners do a H+P with every new patient. Although, I have to admit, I am sick of the primary care guys that don't have an index finger long enough to do a rectal exam.
 

There has been plenty of ranting on this and other medbolg sites about "the death of the H & P." An inordinate number of us apparently feel that this is an antiquated and and at best amusing exercise, what with CT's, MRI's, PET's, cath's, endoscopies etc.

Is it any conicidence that there is an equally vociferous rant going on about "proceduralists" (and the obscene aomunts of money they make)?
 

anon 7:51

You apparently work in a good clinic that upholds basic standards. I too thought it was what "everyone" did, until I began doing reviews for Medicaid. It is not just a matter of not documenting because I follow these up with conversations. Many proceed immediately to the profitable expensive services that are unneeded without asking for or looking at what would tell them that it is unneeded or was just done somewhere else. Then there are the H & P's with every physical exam computer generated and identical--with non sequitors like full normal cranial nerve exams on delerius combative patients.
 

Please explain how the primary care doctor sees any profit in ordering MRIs. Long exam or brief exam, the test is done by radiology centers, not private primary care practices. Most often, the ordering of the testing is done at the request of patients who, guess what, aren't satisfied to be told that an MRI probably isn't immediately necessary and that time and observation with conservative treatment might be just as worthwhile and much cheaper. After awhile, the primary care doctor tires of trying to educate the ignorant who don't want to hear that they don't need every test their friend had or that their medical-associated relative mentioned or that they saw on TV. The patients don't really want the opinion of their doctor.

MR and other testing should cost patients more than it presently does. If you want doctors to spend more time doing detailed examinations, you might want to pay for that service as if you valued it. But complaining that you don't get a comprehensive H+P in a crummy six minutes--all that most carriers will pay for--is imbecilic. You might as well complain that it is too dark at night.
 

Agree with Anonymous 10:49 AM
Patients-especially those who don't have to pay for every test up front, because they have Medicaid or insurance, go right on demanding the test du jour last heard from Sanjay Gupta, CBS, NBC, ABC, Rush Limbaugh, Jon LaPook, Nancy Snyderman, etc.
They dont want to hear the findings of their primary docs, esp. if the next mid-level in the group or the next provider down the hall or street will order what they want!
Or else, if you want to do a good H+P - get everyone's wrath for being "slow".
Worse, be ready to listen to all the manipulative non-sense patients will tell to get the test or drug they aimed to get out of you in the visit. They don't come with tags announcing their agenda either...so u end up working up to look for negatives just to do no further or lesser harm beyond what the patient with instant-answers-now mentality set-out to get in the first place!
 

TO THE "COLLEAGUE" whose parents got thousands of $$$ in unnecessary procedures:
-whatever ailed them, were they found out by history and physical exam alone?
-were they forthcoming with information that could have led their clinician to order the correct tests in the first place?
-how many of those tests were or were not part of mandated testing from guidelines issued by subspecialists and societies? have u considered that your "colleagues" wanted to do your parents good by getting them in the correct path of taking care of their health - knowing that they are your parents - and like many parents of providers, think they are exempt from getting to doctors like the rest of the flock?
-in this era of instant answers, and vague, overlapping symptoms and complaints...when was the last time anybody diagnosed a pre- or new diabetic not yet had overt complications, by history and physical alone?
-when was the last time anyone anticoagulated a possible DVT or PE without documenting same?
-will somebody who faints and sometimes irregular pulses get a pacer without testing?
we can go on and on...but the paradigm of practice in the trenches has changed tremendously, yet a great many [with agenda or not] continue to bury their heads in the sand!!!!!
 

Holy Cow, Anon 7:51 PM!

I am one of your primary care colleagues who has a short index finger to reach even the rim of the anus of age 50+, 180+ lb diabetic with pear body shape, has mild anemia, won't do stool cards, and would need an endoscopy, anyway!
Shall I waste my time poking my finger in his rectum just to satisfy your inclination? Shall I strain my back and arm[s] to reach that bottom? Please, get a grip with those long fingers!
 

I don't get it. There is so much complaining about the number of patients to be seen in a day, but the rationale for NOT doing a decent H & P is that this patient wants a lot of tests instead and if you dont't order them, he'll go down the hall to your partner or competitor to get them?

SO WHAT? Do you really want that kind of patient in your practice? Don't you have LOADS of other patients waiting to get your attention? Since you personally don't get any $$$ from those tests and therefore haven't any issues of secondary gain, what have you lost?

Why not take care of the hordes of patients who WILL comply with your advice (including those bad ole tests) when YOU think they're indicated, and which YOU think will actually help manage the patients' disease?

There is something very disingenuous about the argument that you have to do tests, consultations etc just because the patients demand them.

The argument isn't that there is a choice BETWEEN a decent H & P and tests, consultations and procedures. It's about all the UNNCESSARY tests,, consultations and procedures that result from sloppy H & P's, or as admitted to above, sloppy clinical habits ("cuz the patient WANTED them!").

In the final analysis, you get the kind of practice you cultivate.
 

This post has been removed by a blog administrator.
 

Anon 4:37
-clinical practice is not like selling hamburgers at Burger King; the customer [patient] who wants a fish sandwich [test or treatment 1] while he really needs a whopper [test or treatment 2] cannot be turned away by the provider [store] just because the customer demands 1 product over the other and would not communicate a history or manifest in front of the provider an allergic reaction to fish or beef [as in a history & physical exam]

-a lot of clinical practices and practitioners also get imposed upon them patients [so the practice will thrive? or if u are in the public health arena]; also by law and ethics, a patient who is new - needs to be attended to - before they can be sent away when they're found out to be a 'have it your way' kind of patient
Hope thess made sense?
 

Getting a history and physical on a regular basis may seem like an antique of medical practice.

As we grow older in the particular body we were given, certain bad things are likely/rarely to occur, as the individual case may be.

What physician is better at guiding us thru life? It seems to me that the imaging test of the day will be of minimal value over the long haul.