Many doctors order tests rather than do a history and physical

“Take a good history, do a good exam.”

I have not contributed to my treasure of quotes with this title.  No one reading the headline well hit their head and mutter, “Wow!”  Yet one can wonder about the lack of careful history taking and basic physical examination skills.

This delightful new blog post written by an internal medicine resident says it well: Defensive medicine supersedes quality medicine.

You should read the entire post and the link to the article that stimulated it.  How does a post with that title stimulate me to write about history and physical examination.

Here is the main idea.  Rather than doing a careful history and physical, many physicians resort to order expensive tests based on a complaint rather than a full history.  Physicians almost unanimously believe that other physicians do this (and some will admit that they are guilty also):

Our predecessors were able to gather essential pieces of clinical data from a physical exam. Today, in the world of overburdened emergency departments, full hospitals, and electronic ordering and note-writing systems, we are forced to spend less and less time with our patients. In an attempt to compensate for this problem, we make up in quantity what we cannot provide in quality – and we make up with money what we cannot provide in time. Although the perception is that patients benefit, by getting a myriad of lab tests and imaging studies, they do not. These tests mean very little unless they are correlated clinically. They only become significant in the setting of the patient.

Rather than realizing this, clinicians have begun to practice test-centered medicine rather than patient-centered medicine. This causes huge delays and expenses in patient care. It also places patient at risk for (1) being treated unnecessarily for incidental findings and (2) being exposed to unnecessary radiation. Furthermore, it alienates patients even further from their physicians – and this, perhaps, is the greatest cause of increased lawsuits and patient dissatisfaction, which starts the cycle of practicing defensive medicine all over again.

I would add to these insights taking the time to take a careful history.  I recently met with some new third year medical students for an hour.  We did a special student only morning report.  I spent most of the hour focusing on how to take a careful history.  We discussed the value of certain questions.  We discussed who we might construct questions.

I recommended that they all read the first chapter of Cope’s Early Diagnosis of the Acute Abdomen. This book has the best introduction of the history taking process that I have ever read.   While I am obviously not a surgeon, I have learned more by reading this chapter than any other single source for improving my history taking.

I believe that I have also learned much about history taking by reading mystery novels.  Of course, it may just be that I love reading mystery novels and want to justify that hobby.

Often in my role as a ward attending I find that a careful history helps us make a diagnosis without needing shotgun testing.  Less often, but just as important, a targeted physical examination helps us make a diagnosis.  But doing a careful H&P does take some time.  Learning to take a careful history, reading the patient, adjusting ones vocabulary to the patient are skills that need practice and cultivation.

I challenge all attending physicians to spend time teaching this important skill.  I challenge all residents to find a mentor to help them become excellent at taking a history.  It helps greatly.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • SteveBMD

    I get paid the same amount, whether I do a complete H&P or simply refer the pt to the lab or to radiology.

    If you want to change physicians’ behavior, there’s a place to start.

  • http://www.BocaConciergeDoc.com Steven Reznick MD FACP

    Getting to know your patient thoroughly by taking a complete history and doing a thorough exam is the cornerstone to accurate and complete care. Tests are supposed to be used to support or refute your hypothesis or differential diagnosis.
    I have been fortunate enough to teach medical students from the University of Miami Miller School of Medicine in their history and physicial diagnosis course as a clinical preceptor. This concept is not lost on faculty and mentors at U of Miami who developed and oversee this program and who do an outstanding job of teaching their students history taking and physical diagnosis and its appropriate role in the clinical setting.

  • azerdocmom

    Sad, but true. We have started to take care of the chart rather than the patient. Phrases like “pad the chart” and “CYA” are heard all to often.

  • http://www.medbillingncoding.com Adam Alpers, DO

    I also train medical students throughout the year at my office. We discuss this very topic regularly during the training month. I think that years ago when there were less options available to providers, they were the best at their skills, they had to be since there were less available diagnostic tools available to the degree in which they are today.

    The subtle signs that are clues to disease are lost today in teaching to the level in which they were years ago.

    The day of the true diagnostician is for all intent purposes gone. We need to return to the days when using your physical exam skills mixed with your diagnosing acumen puts most of the pieces of the puzzle together.

    On the other hand, the general public is so well trained today that if they sprain ankle, one of the first things out of their mouth is “Are you going to get an MRI to see if there is anything wrong?” and then you spend the next fifteen minutes explaining why they don’t need to get an MRI for their sprained ankle and the “step approach to medicine” that is needed. (That on the other hand could help with the level of coding you put down for the visit for that encounter)

    In addition, the requirements placed on us to obtain authorizations on just about every test we do is again not only a burden to the time we spend explaining the system as the insurance company dictates, it is now part of the education we need to give the patient in order to insure they understand why we are not just sending them over to the test.

    We are in the 21st century and we seem to be going back in time a little with regards to the way we practice medicine. However, the system in many different areas is creating the pathway we choose in our ability to practice quality “standard of care” medicine in today’s climate.

  • drhawk

    This is sad, true, and completely out of our control. I trained in Australia, and had very intensive training in taking a h and p, and examining to find subtle clinical signs that would indicate disease. Quite often, the tests were simply not available.. sometimes this is a good thing, and other times serious disease went undiagnosed. of course, there was no real risk of liability, and patient expectations were a lot lower, as was their propensity to take legal action.

    Flash forward to the USA. I lost a lot of my clinical skills during my first year of residency. quite often, there was just no TIME to take a careful H and P and do a complete exam. order tests based on complaint and based on your quick PE. 5 minutes was often too long to spend in a room when there were patient waiting, and new ones waiting to be seen in ’30 minutes or less’.

    The expectations of the patients is also different. forget just doing a CT, more and more people are coming in expecting a MRI to diagnose their non-acute condition, tell them no, well mr press gainey has something to say about that!

    I wish people would stop blaming the physicians for the system as it exists. This comes from the politicos, the vast majority of ‘laymen’ and now from the ivory tower as well.

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    I remember reading Cope’s Early Diagnosis of the Acute Abdomen. We have a new method today for examing the abdomen. It’s called a CAT scan.

  • paul

    i would argue that in this day in age we have to strive to do both what is best for the patient and our own legal protection to the extent we are able.

    with that in mind, my practice is to take a good history, perform a good physical, and order a ton of tests. that ought to cover both bases.

  • Jay

    I have been continually frustrated since my days in medical school that the perceived mark of medical sophistication among trainees is the number of tests that one can think of to order. This thinking seems to be encouraged by many who train young doctors. I think that being sophisticated means thinking through the facts of the H & P to limit the number of tests one needs. But it’s easier to order a lot of tests than to think.

    One other thing that often gets left out of the picture: a good family history. This takes additional time and effort, but it’s cheap and often effective.

  • Rajaram Pagadala

    History and Physical Examination by a Physician
    “Take a good history, do a good exam.” Is a soul searching slogan. Slow coaches in the field of medical education are slow to grasp the success of doing a physical examination. I have been a medical teacher (Professor of OBGYN) for over 4 3 decades and established and was Dean of 4 medical schools. I always practiced and insisted simple history taking and performing physical examination where by patients gets satisfied first and the physician arrives at a tentative diagnosis.
    The article by Robert Centre should be an eye-opener not only for the medical teachers but the medical institutions must be ashamed of appointing such teachers who does not take the history and perform physicals. The accreditation authorities are blind to what is happening in medical schools and deaf to the teachings especially in the clinical departments.
    Currently in many schools around the world there is no proper teaching, bedside clinic are rare. Doctors do not ask the name of the patient leave alone taking their history. Thanks to the physician assistant who does the donkey’s job of doing the clerical work with reference to complaints in brief and worry about the type of insurance the patient has. Details are mandatory. But the physician orders battery of investigations without even touching the pulse.
    It is pity if the author feels that “I have not contributed to my treasure of quotes with this title. No one reading the headline well hit their head and mutter, “Wow!” Yet one can wonder about the lack of careful history taking and basic physical examination skills.” I am shocked that the medical profession has been practicing ‘defensive medicine and not any more the quality medicine’. But their income is assured and income tax is paid. Lest IRS will be after them
    It is ironical that ‘rather than doing a careful history and physical’ almost all physicians order expensive tests based on the complaints about which the Nurse Assistant has taken. I am also surprised that some physicians admit that they are mimicking ape in following others who do not take history and perform a physical examination but write battery of investigations. How stupid it is that the thinking of the most intellectual class of society-Physician has degraded.
    It is true that a wealth of information can be gathered by asking few basic questions directly by the doctor. It is absurd to think that the present day doctors are over burdened. They are over eating in the hospital mess making a mess out of their lives when it comes to taking care of a patient. The e-history taking, e-ordering tests, and e-prescribing is playing with the lives of the patients who are misdiagnosed, over-prescribed and gain no confidence from the patients. It is like playing video game in a parlor and pats themselves on their back having one the bogus game.
    In the bargain the costs of medical treatment has skyrocket with millions joining the gang of uninsured. Prepare to take the risk though they will buy a coke to relax while they are suffering from pain and disease.
    It is true that history taking is an art based on the complaints the patient complains off. Performing a physical examination is like mining for rare metals. No doubt it is a challenge in the present scenario of medical education which is at its worst cross roads.

  • http://clinicalposters.com Kevin

    All this time I thought it the physicians I picked just happened to be the ones lacking proper H&P skills. Now I realize the issue permeates the industry. Before joining an HMO, I had the freedom to visit whom ever I chose. For several years, quite a history was built with radiology reports, suggested remedies, etc. though none quite got to the root cause.

    The new HMO primary physician totally ignored history, choosing to reorder the same lab tests. In the end, elimination of an environmental contagion provided a solution after 10 years of suffering. This is something that likely could have been remedied by spending 10 minutes more during the initial consult.

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