how to play "stop the clock"

 

I retired after thirty years practicing Family Medicine out of fear.

I didn’t leave because of the long hours, or the fact that I’d been running hopelessly behind schedule all day, every day for three decades. I didn’t leave to take an easier position or to make more money. I didn’t ask to be excused because of fatigue, or forgetfulness, or ill health.

 

What scared me was the inevitability that I would miss a critical diagnosis, and because of it, I would subject the patient to unnecessary and inappropriate testing and treatments...all because I didn't get the patient's full history. I didn't know the whole story. Who had time to listen? Who had time to search for hidden clues to the diagnosis?

 

"I think of my patients as

body AND mind;

the more I understand about both of these,

the easier it is for me to help."

~Dr. McKenzie Mescon~

 

This fear reflected, in part, the trend toward productivity requirements that link complexity with compensation. Briefly...a doctor generates more money by seeing more complicated patients in less time, and by utilizing fewer diagnostic resources in their care. This is a sure recipe for disaster.

 

Let's say a patient presents with a sore throat and fever. His health care provider checks his throat and ears, and feels around for swollen submandibular lymph nodes. A throat swab is negative for Strep. But because he's running behind schedule, and only has ten minutes to see the patient in the first place, the provider fails to palpate the enlarged supraclavicular node that would have tipped him off to the real diagnosis...the lymphoma that was simmering out of sight. The lymphoma that was causing the patient's night sweats, fatigue and weight loss that no one asked about. It has happened. 

 

"The important thing is

not to stop questioning."

~Albert Einstein~

Details go missing all the time. 

Health care providers have to deal with time constraints. There simply is not enough time in the schedule to invite every patient to elaborate on the details of his medical history or symptoms. The provider gets the basics down, but then he is left to jump to conclusions or to dismiss further input that might otherwise affect the patient's treatment and prognosis. For example, it's bad enough when a patient presents with a broken arm after falling off a ladder at work...but it gets complicated if the patient fell because he was drinking on the job. That's a whole different problem.

The provider is also tethered to a coding and reimbursement system that doesn't compensate him for the time he takes with his patients. The EMR does not reflect psychosocial, emotional, or relational complications of illness or injury, all of which affect the patient's ability to heal.

In addition, people are busy. They're in a hurry. They may have to squeeze in a quick visit to the doctor between meetings or other commitments. To save time, they may minimize or dismiss their symptoms. For example, the patient may not want to stick around while you run an EKG for what he wants to believe is a case of indigestion. If the doctor has taken the time to explore the symptom, though, he may suspect angina...it gets worse when the patient climbs a flight of stairs, or he sometimes feels it in his jaw, or it makes him dizzy. It's not just a little heartburn.

 

Another problem is the fact that the patient may not have the language to describe his symptoms. To a doctor, there is a difference between lightheadedness and dizziness, episodic pain and steady pain, fatigue and weakness. They mean different things and imply different illnesses, and that may take some sorting out.

 

"It can be argued that

the largest yet most neglected

health care resource, worldwide,

is the patient."

~WV Slack~



Patients may also withhold information out of shame, fear, or guilt. Alcohol, tobacco, and drug abuse are prime examples. STIs  are another. Any behavior, or practice, or habit that contributed to their illness, or heartbreak, or regret is part of the story that needs to be told before healing can begin.

 

It can be as much of a challenge for patients to tell their whole story as it is for physicians to ask about it. 

Some time ago I related the history of a patient who claimed her left orbital blowout fracture was the result of a fall causing her to strike the corner of her TV...when in fact, it was the result of a blow from her boyfriend's fist that required me to secure a PFA and to find safe shelter for her. That took time, but it may have saved her life.

 

Isn't that what physician productivity is really all about? Time constraints, reimbursement issues, and productivity aside...we are here to deliver high quality, compassionate, and complete health care to our patients...not to play "stop the clock" with them.

"You define what is important to you

by what you dedicate your time to."

~Vishwas Tiwari~

jan