As a second year medical student in 1971, I still remember an article in the prestigious New England Journal of Medicine, describing a new phenomenon, The Emperor’s New Clothes Syndrome. It was based upon the famous Danish author, Hans Christian Anderson’s fairly tale from the 1800’s.
A vain emperor, who cares for nothing except wearing and displaying clothes hires two swindlers who promise him the finest, best suit of clothes from a fabric invisible to anyone who is unfit for his position or “hopelessly stupid”. The emperor’s servants cannot see the clothing themselves, but pretend that they can for fear of appearing unfit for their positions and the emperor does the same. Finally the crooks report that the suit is finished, they mime dressing him and the emperor marches in procession before his subjects. The townsfolk play along with the pretense not wanting to appear unfit for their positions or stupid. Then a child in the crowd, too young to understand the desirability of keeping up the pretense, blurts out that the emperor is wearing nothing at all and others take up the cry. The emperor cringes, suspecting the assertion is true, but continues the procession.
The moral of the tale is to never take someone else’s word for the truth. In the practice of medicine, this mandates doing your own patient history, physical exam, and review of lab and diagnostic studies. Only then can you formulate your diagnosis and treatment plan. Unfortunately, like many other things in life, what works in theory often doesn’t past muster in real practice.
As a medical intern, I had to work up and evaluate more than a dozen admissions one night and have them ready to present to residents and the attending physician at 7am for morning report. To ask every patient a detailed history, family history, and 14-point review of systems (ROS) was just not possible. Rather than risk appearing inept and unprepared to my teachers, I simply repeated some of what a previous scribe had recorded. I was not alone in this hazardous practice, as my peers all did the same. What was at stake of course was missing the truth due to lack of objectivity.
With today’s pressures of increased patient throughput and declining reimbursements, the problem has only gotten worse. The electronic medical record, (EMR), has made it easier and quicker to copy, and then paste these results multiple times over. Sadly it seems that we all too often rely upon the initial history from the most rushed doctors of all, the emergency room physicians. And increasingly that history isn’t even from a doctor, put rather a physician extender. Thus, both big and small mistakes are repeated over and over again in the chart. I have seen erroneous past surgical histories, like coronary artery bypass grafting noted, when a simple glance at an unscarred chest would have refuted that fact.
We can point to intellectual laziness as a root cause, but as much to blame is the manner in which we are reimbursed. We are constantly reminded not to “over-code” hospital and office visits without including an entire laundry list of H&P points which must be described. To do so risks a Medicare “take back” audit or worse. So we just keep piling in irrelevant junk to survive potential audits. There is nothing truly irrelevant in an H&P you might say and you might be correct.
However, if my goal, as a cardiologist, is to make an accurate diagnosis of the cause of chest pain, does a detailed examination of lymphatic, skin, and eyes help me? Ditto for a complete past surgical history that includes arthroscopies, skin cancer removals, hysterectomies, etc. I know that the skin cancer could have been a melanoma, which now might have metastasized, causing malignant pericarditis and therefore chest pain. But how common is that?
When I am faced with a dozen chest pain consults in one day, I’m not going to dwell on a past history of pertussis, or a detailed neuro-psychiatric exam. Likewise, when faced with the daunting task of seeing office patients every 15 minutes, it is difficult to repeat a detailed ROS on each patient at every visit.
In the end, I can often guess the etiology of the patient’s chest pain after a brief H&P, review of the EKG, and cardiac enzymes. Everything else is just required documentation to allow me to bill for my services at an appropriate level. It does nothing to improve the care I provide to my patient.
Insurance cares more about documentation and check boxes than it does about accurate diagnosis and treatment. We are mired in forms, click menus, workflows, and protocols. Third party tyrants demand the “appearance” of a complete evaluation rather than the time efficient and proper care provided their patients.
Finally I reminded of yet another story that I heard, which may or may not have been true. A tourist came upon Pablo Picasso in the streets of Paris, and asked if he could sketch her portrait. After agreeing upon a price of 10,000 Francs, he proceeded to have her sit and finished a stunning drawing in a mere 20 minutes. Although appreciative of the final product, the purchaser was aghast at the time utilized for the rendition. “I paid you all that money and it only took you 20 minutes to complete!” she yelled at Picasso. To which he responded, “No Madame. This actually took me 20 years.”
David Mokotoff is a cardiologist who blogs at Cardio Author Doc. He is the author of The Moose’s Children: A Memoir of Betrayal, Death, and Survival.