When it comes to the review of systems, I’ve been a natural, a savant — a prodigy you might say.
During my first few weeks of medical school, I remember doing mock interviews with fake patients. This was long before I learned anything about “HPI,” “ROS,” physical exams, billing or anything medically relevant for that matter. As other students stuttered, trying to figure out what to ask a lady pretending to be schizophrenic, I calmly sat in front of her, going head to toe, asking a variety of questions, just to pass the time and to not appear incompetent.
Does your head hurt?
Does your eye hurt?
Does your heart hurt?
Does your belly hurt?
Does your leg hurt?
Does your skin hurt?
And so it went for three or more minutes. After that, my colleagues and teaching assistants marveled at my ability to pepper her with so many questions with no guidance whatsoever. I was born for this — the ability to comfortably take a good detailed history and put it together to diagnose and treat anything that might come my way.
As a primary care internist, my ability to take a good history continues to serve me well every day. But I loathe the review of systems that multi-system checklist of endless questions, taught as a necessary skill for every physician, but in reality is just a force-fed requisite of every patient visit created by the billing god Hades himself and fellow deities at the Center for Medicare and Medicaid services.
Knee pain? I will ask you about seasonal allergies. Level 3 billing. Meh.
Hypertension? I will ask you about rashes. Level 4 billing. OK.
Chest pain? I will ask you about your memory. Level 5 billing. Hades is pleased!
In all seriousness, a skilled physician can and should ask about all the relevant systems necessary to make a proper diagnostic and treatment plan. But the reality is, many of us mindlessly go through this ritual on too many visits, without any purpose except to meet documentation and billing requirements. And in the current state of medicine, where visits are condensed to a few minutes, (many of which are occupied by the EMR) spending even 60 seconds going through the ROS checklist is a misuse of time and energy. It’s mindless work, and that’s frankly insulting to the skilled physician who sincerely thinks about each patient and carefully chooses what to inquire more about.
It’s time to get rid of the review of systems, as the first step in a major overhaul of what’s required of us for billing.
Shabbir Hossain is an internal medicine physician who blogs at Shab’s Sanatorium.
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