Mea sententia

'Taking a history’ is one of the first clinical tasks medical students are taught. The logic behind this is inescapable: without the history, attempts at diagnosis and treatment are doomed to failure. We start our training with the history, when we present patients for discussion with other doctors (in training or later, in practice) we start with the history. And except in rare emergencies, we start every patient interaction with the history.  The history: it always starts there but it doesn’t end there.

The appointment was for his annual physical, and to review his well controlled hypertension and gout. After we had addressed these issues, I asked if there was anything else he was concerned about.

Having problems is not a problem. Believing or pretending there are no problems, and then punishing or marginalizing those who want to fix the problems - THAT is a problem.

In a previous post I talked about some important questions I ask myself in my attempt to avoid missing the correct diagnosis.

There is also a set of questions I like to ask the patient, usually at the conclusion of the visit while I am typing our collaborative assessment and plan into the EHR, to ensure that the patient and I are literally on the same page. 

I have a serious problem with the ubiquitous use of 'due' when talking with patients about what their medical options are. This came up recently when I was given a list of my patients who were ‘due’ for certain services, required if my institution is to receive a financial quality incentive. Typically, ‘due’ shows up in EHR alerts (the diabetic patient is 'due' for their A1c or microalbumin) and quality programs (patients are 'due' for a mammogram every 2 years, a DXA at 65, a pneumovax at 65, even well child visits at set intervals).

Treating patients with chronic pain is one of the more challenging tasks in primary care:

Ordering periodic urine drug screens (UDS) on patients being treated with opiates for chronic pain has become so common it is now the de facto standard of care. That doesn’t mean it benefits patients. 

Every year when I brought my chain saw in to be serviced and have the blade sharpened, Reggie tried to get me to buy a set of chaps. They weren’t cheap, and, while I was not the least bit sanguine about the destructive power of the saw, I used it infrequently, only in good conditions, and with care. The chaps were a garish orange, and I always declined.  Reggie always shrugged, looked disgusted, and rang up my bill.

A few years ago, when he made his usual offer and I declined, he looked at me for a very long moment, and then said:

I love taking care of patients and have enjoyed my 37 years (and counting) as a primary care physician.  When I stop, it won’t be because I am rich, bored, or have lost interest. It won’t be because I am tired (though I am). It will be because of friction.

The 15 minute appointment slot is dead.  To borrow from Monty Python, it is not resting, stunned or pining for the fjords, but definitely deceased, stone dead, is no more, has ceased to be, expired and gone to meet 'is maker, a stiff, bereft of life, run down the curtain and joined the bleedin' choir invisible.