By Dr. Mark Crislip, Infectious Diseased Expert, Science-Based Medicine, Old Doctor Yells at Clouds, January 22, 2024
Half-assed was the term my father often used to describe the result of my chores around the house as a kid. In retrospect, I can’t disagree with his assessment. I wish I had asked him before he died if a good job would be full-assed or zero-assed. I guess it depends on whether the goal is full or zero.
But I have been impressed with how often the basics of medicine are perfunctory. Cursory? Desultory? Superficial? No, I’ll stick with half-assed.
What I am referring to is so many health care providers I am in contact with as a patient or an observer (such as when my wife or mother sees a doctor) do a half-assed history and maybe a quarter-assed or three-quarter-assed physical.
It is sad.
When I have a medical problem, I organize the history before I see the care provider so they get a classic presentation of the history of the present illness, like I learned as a medical student. Six minutes tops, succinct, and perfectly organized. So I know my providers are getting the right information to make a diagnosis. I do recognize there is the problem in that my presentation also includes my bias as to what I think my problem is. I am well aware that, in regards to my own health, I am not the most reliable of historians or clinicians. The doctor who diagnoses himself has a fool for a patient and an idiot for a doctor and all that.
But for some family members, I have witnessed the most superficial of history taking. I know why. The abdominal pain that brought them into the ER? Going to get a CT to see what’s going on. So why bother with a careful history when the technology and blood tests will likely reveal the diagnosis? I am old and old school. I was taught and practiced that a careful history determines the diagnosis and then the tests are ordered to confirm that diagnosis, not to make it.
And when the CT is negative, everyone looks baffled because they have not bothered to make a clinical diagnosis first. Surprise.
I also find that providers rely more on what they read in the chart than what the patient has to say. And that is always a mistake. I learned early that the best approach to a new patient was to go in mostly blind and gather the information needed from the source. I was kind of an asshole, for when I was called for a consult I told them I wanted no more than a 5-word question they wanted answered. I assumed everyone else had it wrong and the approach occasionally paid off.
And the exam?
How many heart /lung exams have I seen that were both brief and through the gown or shirt? Too many to count. One anesthesiologist’s stethoscope was not on my chest for a complete cardiac cycle. It is rare to get a cardiopulmonary exam done that I think would provide any meaningful information to the examiner.
And abdominal exams? Usually, a brief push on the belly while the patient is sitting up. I have yet to see anyone do the classic look, listen, percuss, and palpate.
Most of the time, I just laugh, as I know the exam isn’t likely relevant. I have no cardiopulmonary issues and do not need a heart or lung exam before surgery. It is not like they are going to find an undiagnosed aortic stenosis that might cause an issue with anesthesia. But it might be with the next patient if they bothered to really listen.
So why are the exams so half-assed? I think two reasons. One is that technology is better than the exam, although more expensive. You will get more information from an ECHO or a CT or an ultrasound or an MRI. Or even a chest X-ray. My pulmonary attending years ago said the lung exam is what you do while waiting for the CXR to develop. And I kind of agree with that.
But finding pathology is fun and, on occasion, you will pick up pathology that the technology will miss. Little things, but important. How many times did I note the patient had blue sclera and talking with the patient revealed they likely had Ehlers-Danlos, unnoted for decades? Or the embolic event in the nail bed that meant endocarditis? And the exam can confirm what you think is the diagnosis from the careful and complete history. If you bothered to take one.
The main reason these exams are half-assed? Docs can bill at a higher level if they do them. So even if you have no heart or lung issues, you will get a half-assed heart-lung exam to bump up that billing code. I never did that. I was told many times that I could bill more if I did, but I never thought it was ethical to provide unneeded care for the sole purpose of billing. Everything you do for a patient should only be for the benefit of that patient.
I should add there is a difference between the initial physical and the follow-up physical. An initial evaluation by your HCP should be complete. After that? Likely should depend on what the problem is.
I will say the exam is not always half-assed with all health care providers. The docs I see often do the exam correctly. But they are all old, at least in their 50s. I have found the younger the provider, the more half-assed. And, sadly, MDs are more half-assed than NPs or PAs.
Grumpy old fart grousing about the youngsters today. And get off my grass.
You may read the entire article here.
Bruce Gerencser, 67, lives in rural Northwest Ohio with his wife of 46 years. He and his wife have six grown children and sixteen grandchildren. Bruce pastored Evangelical churches for twenty-five years in Ohio, Texas, and Michigan. Bruce left the ministry in 2005, and in 2008 he left Christianity. Bruce is now a humanist and an atheist.
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