Preserving the Medical Encounter
- 1. Department of Medicine, University of Massachusetts Medical School, USA
Citation
Tulgan H (2018) Preserving the Medical Encounter. JSM Health Educ Prim Health Care 3(1): 1040.
EDITORIAL
At the turn of the twentieth century, Sir William Osler taught us, “Just listen to your patient, he is telling you the diagnosis.” [1]. Osler realized that medicine is not only a science but also involved interpersonal relationships and human understanding. Yet, by the turn of the twenty first century, it was recognized and recorded that the time allotted to patients to respond to an examiner’s questions averaged between eighteen and twenty three seconds! [2], this continues to be true with much of the time dedicated to answering to rote questions.
The reasons for the truncation of the patient-doctor encounter are many. Clearly, the pace of practice has changed monumentally, in part by the evolution from solo practice to the vast number of practitioners who are parts of increasingly large healthcare systems and the corresponding management of their time and demands on productivity. The forced implementation of Electronic Health Records and Computerized Physician Order Entries has only exacerbated this issue as has recently been well documented [3], and other required computer based authorizations is estimated to take up to twenty hours a week away from practice time. In addition, the development of increasingly sophisticated diagnostic modalities appears to have prompted almost immediate referral to them to arrive at a diagnosis in the place of a comprehensive physical examination. Is the traditional history and physical leading to a diagnosis a thing of the past? Medical schools have played a role by deemphasizing these skills by nearly eliminating Physical Diagnosis in their curricula. The “art of medicine” is being lost and the high esteem with which “superb diagnosticians” were held seems to have been nearly forgotten.
There are still ways to approach patients that will maintain traditional roles. These will not only will establish diagnoses but may also save vast amounts spent on unnecessary expensive testing and restore to today’s physicians the joy of practice that too many have lost [4]
First and foremost, allow just a bit longer for patients to respond to questions. (Remember Osler). Clues may be gotten from occupational information, hobbies and travel and these are often overlooked. And I cannot count the number of people who have told me that they were sent off for extensive and expensive laboratory and various radiologic studies without being examined and before a differential diagnosis has been entertained which may warrant the appropriate ones to be done. If an initial diagnosis appears incorrect, rethink it, be on guard for something unique and don’t rush into treatment without a reasonable degree of certainty. Above all, recognize your limitations, learn from your mistakes and never hesitate to seek a second opinion instead of resorting to even more shotgun testing. Patients appreciate honesty and it helps to cement relationships with them; relationships that so many miss.
Recognizing the stress that modern practice places on Physicians leading to burnout and early retirement, the American College of Physicians has recently introduced a Physician Wellbeing and Professional Satisfaction Initiative [5]. Reestablishing our time honored roles with patients should help, too.
REFERENCES
1. William Osler. A Life in Medicine. BMJ. 2000; 321: 1087.
2. Marvel MK, Epstein RM, Beckman HB. Patents Interrupted? J Fam Practice. 2000; 49: 476.
4. Gellin GA. Presidential Address Before the Pacific Dermatologic Association. 1981.
5. Annual Report of the Executive Vice President. ACP. 2017-2018.