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Monday, January 10, 2011

Doing vs. Documenting - Making and Explaining a Diagnosis

Doctors and Patients, Lost in Paperwork

ERproductions/Getty Images

It is a common lament among physicians. We spend too much time doing "paperwork" (computer work) and not enough time with patients. This complaint resonates with patients, who believe that their visits with their physicians are just too short. It sounds so compelling until you begin to ask some basic questions. What exactly do physicians actually do for patients? If direct patient contact is so valuable, who is it valuable to and why? What specific physician activities actually deliver value for individual patients?

Value added activities basically fall into three categories: Diagnostic services (solution shop), targeted value added interventions, and chronic disease management services. Each of these activities relies on different types of work process and has different deliverables to patients. This blog with deal with diagnostic work.

The deliverable for diagnostic services is a diagnosis. This has value because it is an accurate prediction of the future in regards to natural history of  disease and appropriate therapy if indicated. The higher the quality of service, the more accurate the prediction. Diagnoses which have no predictive value are of little or no value. Diagnostic services require the garnering and synthesis a lots of information from a host of sources. A "diagnosis" requires obtaining an accurate history and then applying a variety of diagnostic tests. The history is essential since virtually all diagnostic tests are context dependent and history is nothing more than the historical context. Direct patient contact is essential for the diagnostic process but perhaps we need to ask some critical questions regarding why. What specific tasks related to diagnosis are best done while with a patient? Since diagnostic work is all about information collection and analysis, what specific information is collected better or exclusively with direct patient contact?

An argument has been made that direct contact is essential because of the physical exam. The entire E&M billing process hinges on hitting the various bullets in the PE in order to meet specific billing levels. This is one of the worst cases of the tail wagging the dog. In my experience, there is modest value from the physical exam, which has historically been overrated. When elements of the physical exam are tested and attempts to validate specific elements of the exam have been done, the exam turns out to be not so reproducible. I am reminded of the impact of CAT scans on the bedside neurologic exam during my internship. For years we were  under the delusion that we could accurately map the location of lesions in the brain using bedside tests. When the CAT scan came along as a new gold standard, we realized that such tests should be relegated to history. I may get some credit for pushing on someone's belly, listening to their breathing, or looking in their ears when it comes to billing. However, in the absence of of any symptoms referable to these organ systems or body sites, my exam is not likley to bring any value to the patient, only to me via increased reimbursement.

 In my estimation, there is much more value from accurate historical information. However, it is my experience that much of this information can and should be collected outside the direct patient encounter. It can be collected more accurately and in a more structured format under less time constrained circumstances when not crushed into an office visit. This can and ideally should be outsourced to patients. Using physicians to act as a filter as to what needs to be documented or not leads to missing important pieces of information. This has been highlighted in Evan Basch's observation about adverse drug reactions. Reports by patients were much more complete than physician reported tallies and this allowed for more rapid recognition of adverse events in drug trials.

If the physical exam is of limited value and much of the history can be collected outside the context of direct patient contact, what use is our face time with patients? I would argue that the most important time with patients is after we have collected and synthesized information. At least in my experience, to come up with an accurate diagnosis, account for other items in the differential, consider different treatment options, and put this into a format which is understandable to your patient requires a great deal of work not in the presence of a patient. Medicine is more complicated now than it was in the past and it is nothing short of crazy to believe that you can or should do all of this on the fly during the time allocated by an office visit.

Once you have done your preparative work, the quality time with patients can deal with important decision like what patient really want and what they really fear. That is where real value is part of the direct patient encounter, where information can be applied to address specific human concerns as part of shared decision making. This is also fantasy. The real life encounter is filled with useless muda (, guided by inaccurate and incomplete information, and structured by a flawed payment system. However, railing against paperwork will not get us any closer to fixing the problem.

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