In the early 1900’s, Sir William
Osler, master clinician and educator, pulled medical students away from their
textbooks and into the living, breathing world of medicine on the wards of his
hospital. He believed that the real
learning happened at the bedside with patients serving the role of the textbook.
In the 21st century, it hurts
to now see physicians retreating out of the patient’s room and back into an
office void of textbooks but filled with glowing computer monitors and
electronic charts.
At the Johns Hopkins Hospital,
there is still an emphasis on the physical exam and bedside diagnosis. Medical students are taught how to perform a
thorough physical exam by senior faculty, practice their skills on standardized
patients, and then are shown interesting findings by residents (doctors-in-training)
and attendings (senior physicians leading the medical team) once they arrive on
the wards. But times are changing. With the government cutting reimbursements to
hospitals for the services they offer, there is an emphasis bestowed by hospital
administration to streamline the hospital stay and optimize the billing process
so that more can be paid for. This
single influence has led to a series of changes in the current face of
medicine.
One major change that has become
obvious in many hospitals is the physical disappearance of physicians from the
hallways of the medical wards. At one
time, patients had binders next to their rooms that housed their medical
information, current medications, results of blood tests, and plans for further
testing. When their doctors needed help
from a specialist, that specialist would come by to see the patient and jot
down their recommendations in that same binder. The result was a central focus of attention located
physically at the patient’s bedside. Patients
would see their physicians stop by often, and subsequently, would be able to
ask questions and develop a special relationship with their doctor. If nothing else, at least they saw their
doctors stop by to say “Hello” multiple times in a day which can be therapeutic
or, at the least, reassuring that they have not been forgotten. With the advances made in medical informatics,
the bedside binder of information has become obsolete. Now, every patient has a medical record number
and an electronic chart that can be accessed from any computer in the hospital.
No longer does a physician need to come
to the patient’s bedside to do such things as check test results, read notes
from other specialists, or even order new tests. This proves to be great for efficiency of the
caregiver team. But the doctor-patient
relationship is the casualty here. Patients
often obliviously go to CT scans and have blood drawn without any explanation
or reason. Oftentimes, nurses are the
ones left explaining these complex medical decisions to the patients and their
families. Medicines and imaging tests
are sometimes ordered on the wrong patient because unique patient identifiers
on an electronic chart are often limited to the patient’s name, and doctors are
often multi-tasking when ordering such things. In large teaching hospitals, patients are
often seen by so many various members of a medical team that they often leave
the hospital unaware of who was the physician in charge of their
hospitalization. They remember their
nurses and support staff more than their physicians.
The electronic medical charts at
most hospitals were implemented only secondarily for ease of access of medical
information. The primary reason, and the
driving force behind how these systems are designed, is to maximize billing. There is a focus placed on assigning diagnoses
to symptoms, as these are the key elements that allow the hospital’s billing
department to optimize reimbursement. Many
physicians would say that the written medical record was easier in many ways
and facilitated the bedside presence of doctors. Nowadays, residents and attendings oftentimes discuss
patients in front of a computer where laboratory tests, imaging studies, and
reports from consultants are readily available at the click of a mouse. But I’d argue that the most important aspect
of the presentation is missing: the patient himself.
The answer, though, is not so
obvious. When medical teams do make the effort to go to the patient’s room, the
patient is frequently undergoing an ultrasound or on his way to the MRI
department for a three-hour field trip. With
improved coordination of medical care to hasten hospital discharges and make
room for the numerous patients awaiting hospital beds, the tradition of
“Morning Rounds” where a senior physician accompanies young doctors-in-training
to teach key features of the history and physical exam is becoming a
disappearing art. Young doctors find
themselves to be less experienced in physical diagnostics and more experienced
in ordering tests and facilitating hospital discharges.
Over the past decade, we have seen
the growing presence of the “Hospitalist” physician. Gone are the days of the family doctor leaving
his clinic to care for his own patients when they happened to be hospitalized. With specialization of roles came the advent
of the “Hospitalist”, a physician whose only job was to take care of patients
hospitalized from the community. These
doctors don’t have clinics to tend to and, thus, can dedicate all hours of
their day in coordinating hospital care. This allows family physicians to remain in the
clinic so that they can solve their own struggles of reduced reimbursement
rates by increasing their number of patient appointments. Hospitalists have their own problems though, a
major one being a high burnout rate. Thus,
these positions are often filled by doctors just completing their medical
training who are attracted by headhunters to the job with promises of
loan-forgiveness, excellent compensation, and weekly shift work. These young doctors are willing to put in the
hours for now, but those feelings are sometimes ethereal. In the process, however, it is these young
physicians who sometimes end up leading medical teams at large teaching
hospitals. Young hospitalists find
themselves less and less able to pass on any skills at the physical exam and
bedside diagnosis, and so these problems find a way to jump to the next
generation of physicians. Modern day
apprenticeships are now characterized by teachings on medical informatics,
details of laboratory testing and imaging, and proper techniques for billing. The expectation to complete medical training
with confidence in bedside skills as a physician takes a backseat to passing a
multiple-choice exam and logging your weekly duty hours.
At a growing number of teaching
hospitals around the country, there has been the advent of a procedure service.
In the past, when a patient needed a
special procedure such as a central venous catheter, paracentesis,
thoracentesis, or lumbar puncture, the team of residents led by the attending physician
would coordinate amongst themselves to perform the procedure in a timely
manner. This process allowed the
residents on the medical team to gain experience doing such procedures while
also allowing for the doctor-patient relationship to be strengthened during the
time spent in the procedure. It wasn’t long, though, until hospital
administration realized that they were missing out on key opportunities to bill
insurance companies simply by not having a board-certified physician present at
every procedure. Their solution was a
procedure service. This is usually a
team made up of a board-certified physician, a mid-level (i.e. nurse
practitioner or physician assistant), a nurse, and occasionally a few residents
in training. Now, whenever a patient on
a medical team needs a procedure, it has been commonplace and frankly easy to simply call the procedure
service. Without too much stress endured
by the primary team, the patient undergoes the necessary procedure in an
efficient, cost-effective manner. Additionally, by ensuring that a billing
physician is present, the hospital can ensure that it will be properly
reimbursed for the procedure. But there
is something that is lost in the process. The medical team has yet again been
removed from direct involvement with its own patient. There is less teaching due to the high volume
of procedures that are on the service’s queue, and thus, less apprenticeship. There is also a diffusion of accountability
when it comes to post-procedural complications which can sometimes lead to
compromises in patient care.
I don’t think there are going to be
easy solutions for these problems. The
majority of these changes are driven by a need to be more profitable in a world
of ever-increasing financial stresses, as well as an increasing concern over
diagnostic liability. But one small
thing that can be done is for hospital physicians to place just a bit more
emphasis on teachings of the physical exam and bedside diagnosis. Let’s open up a dermatology atlas and figure
out what kind of rash our patient has instead of reflexively calling in the
dermatology specialists. Let’s ask our
patients to completely undress for a full physical evaluation of every orifice
and bodily crease. Who knows what we may
find? This small act will re-establish rapport with our patients while also
inspiring the next generation of physicians to keep medicine at the bedside and
out of the computer. The physician’s
touch can often be more healing than the reassurance of thousands of dollars of
blood tests and imaging studies. And as
these expensive tests begin to garner less and less reimbursements for the
hospital, the priceless nature of the physical exam may be a large part of a future
solution to healthcare’s financial dilemmas. If that is indeed the case, I sure hope that
the next generation of doctors knows how to even perform one.
Doc Veritas
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