The “Patient Centered” Medical Appointment: You Know the Drill

Health care was supposed to value patients’ privacy and be sensitive to their cultural, religious, philosophical, educational, sexual and socioeconomic background. It was supposed to move the visit agenda and the medical decision making authority from the doctor to the patient. It was supposed to create safe “medical homes” for patients of all backgrounds. It even established certification processes to ensure practices were indeed patient centered.

We are officially recognized as a patient centered medical home, and this is what that looks like:

When you arrive at the front desk for your routine physical, you are handed a form asking you to specify in great detail what your gender identification is.

In the exam room, the medical assistant administers, in rapid fire questioning, a “validated” nine item depression inventory. She then verifies your medications and updates your personal, family and social history. As part of your social history, if you happen to admit to being a smoker, a “smart form” with followup questions pops up with questions from “How many minutes after waking up do you smoke your first cigarette?” to “How ready are you to quit?” Similar questions about alcohol use follow.

If your visit happens to be a Medicare annual wellness visit, you are also bluntly queried about anxiety, sexual difficulties and history of falls as well as anything you want to confess about messing up your medication regimen. And, perhaps most invasive of all, if your body mass index is higher than ideal, your doctor will be required to document a treatment and followup plan to manage your overweight or obesity. If any of these items are omitted, Medicare has the right to demand their money back from your medical provider.

So, after all that, are you still going to be in the mood to discuss your most sensitive issues with your medical provider in the few minutes that remain?

Now, the most amazing thing to me is that people put so much faith in these blunt tools that are promoted as “validated instruments”.

Does a homicide detective ask a suspect “Did you do kill the victim?” and leave it at that? Does a customs and immigrations officer say “Are you a smuggler or a terrorist?” Does a principal ask a prospective teacher “Are you a pedophile?” That sounds about as sophisticated as today’s “validated instruments” in my business.

I still remember when, without using the words “patient centered”, we would sit down and have conversations with patients. We would say things like “can you tell me a little about your habits, your work and your home life?”

And, perhaps most important of all, just a few years ago, the opening phrase in a good medical office visit used to be ”what would you like to accomplish in today’s visit?”

That was before we became certifiably patient centered…

11 Responses to “The “Patient Centered” Medical Appointment: You Know the Drill”

  1. 1 Susan Daly October 26, 2017 at 10:23 am

    One of your best posts!

  2. 2 Jonathon Nicholson October 26, 2017 at 11:48 am

    I couldn’t agree more. And thank you for your posts. I am a physician in Northern Michigan, as rural as rural gets, and you speak truth. I really appreciate it.

  3. 3 Lisa October 26, 2017 at 3:48 pm

    If documenting a treatment and follow up for obesity means merely stating that I’m obese and need to lose X amount of pounds, I guess that counts.

    • 4 acountrydoctorwrites October 26, 2017 at 4:21 pm

      Needs a specific plan, smaller portions, less Sosa, join a gym…

      • 5 Mary Symmes October 26, 2017 at 7:12 pm

        I have begun to avoid doctors unless I have some kind of severe discomfort. I have stopped taking my statin drug. I have lost 20 pounds (more to go) and am thinking of stopping the Metformin. I feel better than I have in years. I find many intake forms incredibly intrusive, and simply don’t add items I don’t see as necessary. I watched my husband die a long, complicated death from COPD et al, and his doctors did nothing but give him more drugs and ignore his suffering. I have a very specific Advance Directive and wear a DNR necklace because I don’t trust doctors not to keep me alive just because they can, although I do trust my personal physician. I am really tired of being treated as a body part.

  4. 6 meyati October 26, 2017 at 7:51 pm

    The diabetes-glucose really hit me. I had to gain a minimum of 20 lbs in 6 weeks to start head cancer radiation treatment, because I was too small to survive. You know those 20 lbs went to my middle. I was told not to lose it because of sudden weight failure that neck/head radiation patients can have. I am cancer free.

    I ended up with a PCP that insisted that I have diabetes-then pre-diabetes The HMO was riding doctors hard about obesity. The hemotology oncologist wasn’t onboard for the weight maintainance. I kept saying that my MD Anderson radiation oncologist took chage of my diet, and he wasn’t consulted by anybody. I started copying my glucose in MS Word. My results were being changed to scare me (the PCP owned the lab).

    A counselor told me to get a sugar stick–PCP told me it was high. I took it to oncology clinic, the counselors, oncology radiation, the HMO office. They all said–How do you get such a low sugar stick? (Sugar is a trigger for my IBSD). My radialogy oncologist went over my labs-looked at my ER visits for low glucose, etc.

    I went to the PCP, trying again to get my thyroid in range, and he screamed at me that my RAD-ONC was on him like a pit-bull. I guess he found out that a MD Anderson radiation fellow was the big dog in the fight, because he lost his license for several reasons. I cannot have been the only patient treated so poorly.

    The good news is that the network finally got its act together and found me a PCP that understands thyroid, and listens to the doctor that saved my life. I have a hard time keeping my weight up. I have a good team of doctors that care for me and the current boo-boo. Ja, I get asked about falling-whatever–

  5. 7 Mark Paulsen October 27, 2017 at 1:19 am

    Well put, as always.

  6. 8 evenstar97 October 30, 2017 at 10:19 pm

    I get your point, however I don’t think filling out a checklist and having a meaningful conversation with your patient have to be mutually exclusive. Quality must be measured somehow, and those measures have to be able to be evidence-based and fair and equitable to everyone. I agree that it should be easier to implement PCMH standards, especially for solo practitioners, however the principles are sound.

    • 9 acountrydoctorwrites October 31, 2017 at 12:00 am

      My point is that the check lists have led to an insensitive drill instead of a discreetly documented conversation.

    • 10 RTW November 10, 2017 at 7:19 pm

      “Quality must be measured somehow”


      And what if it’s impossible to measure?

      • 11 Abroo Nawaz MD November 23, 2017 at 7:44 pm

        Patient surveys could give us some good measure of quality but sadly voluntary surveys are mostly filled by a few unhappy patients and not by the majority who are happy or satisfied with care
        Cliché as it may sound but medicine is indeed becoming a business under the ruse of being patient centric and losing its human touch Physicians are more focused on checking boxes filling templates to fulfil billing requirements than making the much needed face contact with patient
        The system that’s meant to be patient centered is anything but!

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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