Balls and Walnuts
more than you ever wanted to know
Hands-off medicine
Bend over, I need to check your doody.
My Sis was bemoaning the fact that all her new internist did was listen to her heart, look in her ears, and check her throat. Frankly, I’m surprised she did that much. My last three docs (always changing docs because we’re always MOVING, go figure) reviewed my meds, checked my BP, and asked what drugs I needed refilled. End of story. Do you think my wife, who actually has some trouble, gets a closer look? Not really. They like to tap out her reflexes.
Notwithstanding the countless texts written in the 19th and 20th centuries predicated on the value of physical diagnosis (Zachary Cope’s Early Diagnosis of the Acute Abdomen comes to mind, for one), one could make an argument that an internist’s job nowadays breaks down to algorithms crunching raw data: patient’s age? sex? family history? smoker y/n? drinker y/n? list of medications? and so forth. Turned fifty, let me send you for a colonoscopy. Eighteen months since your last mammogram, ooh, you’re overdue for another. Same goes for that pap smear. Not taking baby aspirin, well, take a baby aspirin.
I’m not an internist. I’m a surgeon. I practice physical examination and physical diagnosis with each and every patient I see. I’d be lost without my hands and eyes. Since I’m not an internist, you could argue I have no business criticizing them. And I don’t, and I’m not. What I want is to draw attention to the perception that internists are data crunchers who no longer practice the laying on of hands.
If we notice it, others will, too. Health care administrators, health insurance executives, health care policy wonks and politicians will notice. And what happens when these folks decide that the internist’s job can be replaced by a fairly unsophisticated computer program?
I do think that internists, most of them, bring a lot more to the exam table than would a computer program. I suspect they could argue very well for the necessity of their existence. But one thing I’ve learned in medicine these past 25 years: we doctors have little control over our own destinies. Bureaucrats have done a tidy job altering our professional lives to suit their fancies.
So doesn’t it seem logical that internists should strive to win the perception war before someone without an MD or DO after his name tries to debate them out of existence?
D.
My wife would add that if the internist has a good intake form (and the patient does a responsible job filling it out), reviews old medical records and so forth, that will replace a physical examination to some degree.
Plus, some things are evident to the naked eye (or nose . . . jaundice and uremia have a characteristic smell, for example). Much goes on in the internist’s brain which bypasses the patient’s awareness.
Two points in response: first, this still doesn’t address the perception problem I’ve referred to in this post. And second, you still need to look (or sniff, or listen). No matter how good your eyes, you could easily miss those spider angiomas that could tip you off to liver disease if you never ask the patient to disrobe.
Well, judging by the picture, I don’t have liver disease.
I just hate filling out my history, but you’re right, internists seem to be more about crunching data. My new internist was all too eager to write a prescription for refills on any of the pills I was taking based on this data. She recorded everything on her cold little laptop.
As a teacher, I am being asked to look at data to help my students, and you know how I am about numbers Doug. I had to keep myself from rolling my eyes yesterday when my principal started bringing up that dirty word, data. Like doctors, teachers have become less hands on, but it seems that getting rid of the hands on approach is the wave of the future (thus the online credit recovery program at my school).
Ironically enough, I just watched the news about how new doctors are being trained to have better bedside manners. Just because the patient has cancer, doesn’t mean you treat that patient’s diagnosis the same as another patient who has the same kind of cancer.
About as personal as I got yesterday from my new doctor (better than nothing)when I told her my job as a teacher was stressful is when she laughed and said, “yes, I have two kids.” Que? I asked if she was born in Russia…told her my paternal grandparents were born there, and she asked if they spoke Russian in the home.
Oh, cute picture!