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Sunday, October 17, 2010

The Physical Exam

The New York Times has taken note of Abraham Verghese's efforts at Stanford University School of Medicine to revive the art of examining patients. One gets the idea in this article that most medical schools have let the entire subject slide, which is not true. Nevertheless, enthusiasm for the hands on aspect of data gathering has declined somewhat. When I was in training about 25 years ago, my clinical teachers took the subject of teaching us how to identify pathology in a patient seriously. Johns Hopkins medical school was at that time held up as a model of a clinical teaching institution, so training medical students and residents in the arts of examining hearts, blood vessels, livers, spleens, bones and joints was clearly going to be part of the curriculum. Many patients who moved through the clinics and hospitals associated with Johns Hopkins donated important pieces of their time and dignity in the service of teaching what would be generations of physicians how best to do this. When I finished my training, I felt confident enough to continue to teach myself these skills as I treated and examined 10s of thousands more patients.

The perceived value of the physical exam, however, has taken many hits in the years since I graduated.  Well known and oft quoted studies showed that even specialists in liver disease could not tell the difference between belly fat and fluid in the abdomen, that cardiologists couldn't agree on the identity of the many heart sounds associated with failing hearts and valves, and gynecologists were unable to identify ovarian cancers by physical exam at a stage when it had an impact on survival. Many doctors began to back off on the level of intensity of their examinations, partly because they were not entirely sure whether they believed what they saw, felt or heard in a patient's body. Technology such as CT scans, MRI scans, x-rays, ultrasounds and mammograms became much more universally available, and we began to rely on them more. Very little was said about the fact that these, too, are inaccurate in many cases, and only now are we beginning to recognize the fact that both the radiation and the costs associated with these tests carry a significant toxicity.

A good examination takes some time. It doesn't necessarily take much time, but in the hands of a doctor who is not comfortable performing it, the choreography is tricky. In large practices where doctors are expected to see patients at 10 or 15 minute intervals, there is not enough time to have a patient undress and be examine, document the findings, order the appropriate tests and prescribe the appropriate medications, especially if the physician is expected to actually speak to the patient about what is going on.

Teaching the physical exam is part of the art of medicine. Over the years that a doctor practices, he or she will see many presentations of many diseases and develop theories about what findings are indicative of things such as prognosis, response to treatment and subtleties of diagnosis that were never a part of their training. If that physician has an opportunity to teach, these pieces of knowledge will be passed on to students who will further cultivate it based on their experiences. Many of the "clinical pearls" that are developed in this way can never be scientifically tested, but will have immeasurable value.

Much of the information I get from examining a patient, looking in mouths, listening to hearts and lungs, feeling thyroids and lymph nodes, doesn't influence my diagnosis or treatment of a patient, except due to lack of unexpected findings. As a betting person, since the majority of physical exams are normal, I might choose to simply not do them, and assume that they are normal. It would save a lot of time. But without a physical exam, the two of us, me and the patient in the room, are just talking heads, telling interesting stories. Humans are made multisensory creatures, and our communications are best when they include all of our senses. Even the crudest of my senses, my nose, tells me information that is valuable. The touch of hands to skin is a communication that involves two, and the information flows both ways. A patient can sense my confidence, empathy, skill or lack of it. Facial or body movement in response to my hands tell me what kind of problem, how serious and how the person being examined handles illness.

I appreciate the fact that Dr. Verghese is tackling our lack of enthusiasm for the physical exam, bringing his obvious joy in the subject together with his charismatic teaching style to get a new generation of doctors excited about what they can do with their own hands, ears, eyes and noses. Those of them that teach will undoubtedly allow his gift to keep on giving.

This is a link to the article on Dr. Verghese in the New York Times:

Tuesday, October 12, 2010

What now? What must we Champions of Medicine do, other than not spend $5000 to attend Newt Gingrich's party?

Quite a number of perfectly adequate and hard working doctors have been invited to go to Washington to dine with Newt Gingrich. Most of us have decided not to go, though the tenderloin did sound tempting. But now that we aren't going, and health care reform is most likely a done deal, what is left for us to do? We are the Champions of Medicine, so are we just supposed to throw our capes over our shoulders and ride off on our white horses? "My job here is done..." I will say, as the music starts and the credits begin to roll.

Despite our hard work over the last harrowing year, there are still some problems with the American Health Care System, as it is sometimes called. It is too expensive, costs are rising and people are suffering because they can't get the care they need.

What have we gotten with the Affordable Care Act? We have funding for various projects aimed at making medicine more cost efficient and we have payment methods, public and private, that will make it possible for more people to get medical care at a cost they can afford to pay.

This is a major step in the right direction, but there are some major missing pieces. Mr. Gingrich would like to scrap it and start over, but then he clearly hasn't read it since he thinks we now have socialized medicine. Much of what wants to be improved in medicine can't be legislated, so I would like to keep what we now have and see what else needs to be done.

Costs are still rising and this is, at least at this point, threatening to stifle economic growth at a time when our country is struggling to be competitive in a world market where medical care is not a major part of the cost of doing business. This needs to be turned around quickly.

Despite new regulations requiring insurance companies to make policies cover basic medical needs at a cost that people can tolerate, insurance products are even now getting more expensive and less generous. Our continued reliance on insurance to pay the bills not only limits any incentives for costs of medical care to go down, but makes the insurance companies powerful enough that they will certainly have a significant influence on policy which will lessen the effectiveness of the regulations.

Doctors don't understand the new laws and are fearful and suspicious. This is causing doctors who have been in practice to consider narrowing the scope of their practices so they are less vulnerable to public insurance changes, and in many cases to consider retiring. The widespread experience of being sued for malpractice already shortens the careers of many physicians, and the lack of any serious attempt of the recent bill to solve this problem has disillusioned many of us.

So what must we do?

First costs need to go down.  In looking at everyday medical practice as it goes on in my community it is clear that much of the excess money spent in medical care is due to the whims of care providers, inadequately informed by science and without knowledge of the costs involved. Almost nobody knows what most of the tests or medications we prescribe cost. Merely being made aware of costs, coupled with more widespread education on appropriate use of medications and testing would make a huge and nearly instant impact on medical costs. This can happen, but could be facilitated by our national organizations. If they are unable or unwilling to mandate transparency of costs and provide leadership on appropriate care, we can do this at a local level through working with our hospitals, clinics and pharmacies to share information.

Costs could also be impacted by changing the way physicians are paid. If we were not only aware of costs but were paid to care for a group of patients rather than by the individual encounter, there would be strong incentives to keep patients as healthy as possible so that they didn't require doctor visits or hospital care. This would line our incentives up with what patients really want: for us to keep them healthy and care for them effectively when they are sick.

One way of providing health care of this type would be through community health care systems on a cooperative model. Communities of people already spend huge amounts of money on health care, and if they pooled those resources and that money did not need to move through an insurance company in order to pay for necessary care, it would buy a great deal more health care. The health care bill supports creation of structures like this, but does not in itself make them happen. That is up to us, in our communities.

I'm not sure it is possible to reassure doctors that all will be well as health care reform goes into action, but if our own national organizations, such as the American College of Physicians and the AMA, show leadership in making our own positive changes we will all feel more in control of the process. 

Suing for malpractice continues to be the dysfunctional approach often taken when a patient has a bad medical outcome or a mistake is made, especially if care was very expensive. We can, even now, tackle this in our communities by making ourselves aware of bad outcomes and medical mistakes and offering compensation as well as honestly evaluating what went wrong. This process can be done by hospitals and clinics, and has been shown to reduce costs overall.  Suing for malpractice destroys lives of both injured patients and physicians, as they spend years in rancorous argument, and the medical community then loses the opportunity to learn from mistakes.  Any federal law reforming medical malpractice is certainly years away, since the tort system has traditionally been a way to protect those who are vulnerable, and it is hard to make the case that medical injury should be handled differently from other sorts of injury.

I'm thinking that perhaps there is still quite a bit of work for all of us Champions of Medicine to do. I think I'll save my  5 grand and travel expenses and hotel fees and just hang out here at home and work on this stuff.

Monday, October 4, 2010

Newt Gingrich invited me to a party!

Today I received an invitation to an election day party from Newt Gingrich himself! Apparently I have “made the cut” as one of the 2010 Champions of Medicine and will receive a handsome certificate at an election day party at the historic Ronald Reagan Building in Washington D.C. Newt has confided to me that he has worked tirelessly of the course of his career for health care reform. He understands that I have faced challenges during the Obama administration's first two years and that this year has been especially difficult for me with the “Democrat held Congress essentially dismantling the world’s greatest healthcare system and replacing it with the failed model of socialized medicine.”

Newt wants me at the party mainly because he wants to be surrounded by the best and brightest this country has to offer on the “night we set the wheels in motion to repeal Obamacare and replace it with real, meaningful reform.”


I would love to go! I would have absolutely no hesitation in asking uncomfortable questions and spreading sedition among the gathered faithful. For all the good that would do. But life is so full of really great things to do that don’t involve being in Washington DC on election day. There are long walks to be taken in the woods. There are songs to be sung with friends. There is a conference to be organized about appropriate use of technology at our hospital. There is real information about what is going on in my field to be read and digested and maybe turned into essays on why the finest healthcare system in the world fails to take care of its own at an affordable price, and how it can be tweaked to face its challenges. There are stories that need to be heard, poems that need writing, children to be raised, jokes to be laughed at.

I’m still filled with questions about this invitation, though. How stupid does he think doctors are? Are we really stupid enough to think that the reform package dismantled the finest healthcare system in the world and replaced it with socialized medicine? Why invite me? I’m not even Republican. Could he have invited many thousands of doctors, and if so mustn’t he believe that his message would sway very few of them, since he can’t feed thousands of doctors dinner at the Ronald Reagan building? And if I did go, what are the choices of entree?