Archive for the 'The Ghosts in the Exam Room' Category

The Ghosts in the Exam Room – Part 2

Even Hippocrates acknowledged that medicine is not practiced in a vacuum. He didn’t use the word vacuum, of course, as it first came into use in medieval times. But he did speak of the individuals that influence doctor-patient relationships. He called them “the Externals”. I have referred to them as “the ghosts in the exam room”.

In my previous post I wrote about how Medicare is now scripting entire visit types – don’t follow the script for the “Annual Wellness Visit” and risk having to return your payment from Uncle Sam. Medicare is certainly a ghost in every exam room in today’s medicine.

There are other ghosts that whisper threats or temptations in both our patients’ and our own ears as we talk to each other. All insurance companies try to do what Medicare is doing but most of them don’t have the same clout. From drug companies to malpractice courts there are countless external forces that make their presence known in the physician-patient encounter. We are all aware of this and do our best to still provide a private, impartial space for our patients to share their concerns with us.

But not all ghosts in the exam rooms are authority figures that try to promote their own agendas in our patient encounters. We all bring our own private ghosts in the form of, for us physicians, patients we have learned from or whom we have failed – making us more cognizant of our personal and professional limitations. Most of us also carry the spirits of our mentors with us as we close each exam room door and open our senses and our hearts to each of our working day’s fellow human beings in some sort of need.

I often think of those patients who I knew had something dreadfully wrong with them, even if I didn’t at first know exactly what. I think about the High School senior who came in with a rash on her legs a few days before graduation and turned out to have acute leukemia. I think about the woman who wouldn’t let anyone else biopsy the small lymph nodes above her collarbones, which proved to be metastatic lung cancer. I think about the rugged motorcycle-riding deer hunter who blamed his widespread muscle pains on falling out of a tree stand a week or two earlier; he also had lung cancer. I also carry with me the vivid recollections of patients who made their own diagnosis once I let them speak uninterrupted.

In many difficult visits I also call on my mentors. Sometimes when I seem to be treading water, I think of Professor Boström, who sat in the corner of the exam room crushing tongue depressors during my final exam patient interview at the end of my internal medicine course. When I find myself getting flustered or feeling hurried, I think of Bob Gordon, one of the specialists at Cityside, who never seems to be in a hurry and never seems overwhelmed, even though he sees more dramatic cases than I do. And when I feel pulled between the conflicting agendas in today’s health care – when the ghosts in the exam room won’t stop chattering – I think to myself: “What would Osler do?”

Thinking and reading about the great masters throughout the history of medicine is as important as keeping up with the leading medical journals.

Practicing medicine without understanding, or at least respecting, the history of our profession and the changing nature of scientific knowledge is like sailing on the ocean without charts, compass, or GPS for that matter. You will begin to just drift with the prevailing wind.

Remembering that ours is an ancient calling that has existed in many cultures and under many rulers is necessary when so many forces are vying to redefine our profession.

We need to make sure the scary ghosts don’t outnumber the friendly ones. Because it is very obvious these days in our line of work: We are hardly ever alone with our patients.

The Ghosts in the Exam Room – Part 1

The Medicare Annual Wellness Visit

One of the ghosts in every exam room is the institution that pays many private doctors over ten million dollars, the authority that determines that you can order a BNP (brain natriuretic peptide) to look for heart failure in patients with shortness of breath but not when they have leg edema – you know who I’m talking about – Medicare.

Medicare is not only deciding what services to pay for; they are also scripting entire doctor-patient visits.

As Medicare goes, so goes the nation’s healthcare. Except when it comes to annual checkups. For decades, just about all insurers except Medicare covered annual exams, and even paid pretty well for them. Now that the US Public Health Service Task Force on Prevention has stopped recommending annual exams, Medicare – read Obamacare – has started demanding them. However, they are not paying for the kind of exams patients have come to expect, but a watered-down, scripted event in the spirit of the “Welcome to Medicare” exam that at least yours truly refused to provide from Day One.

I have been brushing off the Annual Wellness Visit (AWV) until now, but it has become a quality indicator that our clinic has to report statistics on, so I need to change my ways.

For the past few days, I have been studying the scripts for the AWV. I have printed up the forms I will need in order to follow the script, since our EMR only has a template for the “Welcome to Medicare” visit, but not for the Annual Wellness Visit.

I have scratched my head about the covered baseline EKG when the USPHS recommends against it, the PSA screening when the evidence doesn’t support it, and several other items on the checklist.

I have duly noted that some clinics, after being audited, have had to call patients back in at no charge to complete missing items on the checklists. I have also noted, although I’m not sure I can comply with, the requirement that any actual physical exam performed during one of these visits requires the patient to sign an ABN (Advance Beneficiary Notice) that they might get a bill that isn’t covered by Medicare. I think I’ll just listen to some hearts and lungs without telling Uncle Sam about it.

Actually, I am a bit surprised that the roll-out of this scripted non-physical didn’t cause more of a stir when it happened. I was only vaguely aware of it. It is quite remarkable that a payer is now micromanaging what happens in the exam room to such an extreme degree.

I am figuratively holding my breath to see what my patients will think of this regimented encounter; they are used to me letting them speak, and me only gently steering the conversation in the exam room. I expect many will feel uncomfortable about the obvious presence of the ghost of the Government in what used to be our private space.

Hippocrates’ First Aphorism

“Life is short, and Art long; the crisis fleeting; experience perilous, and decision difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and the externals cooperate.”

Hippocrates was a wise man. In an era where the causes of most diseases, even the functions of many organs, were unknown, he made detailed and astute observations that allowed him to become a master of prognosis.

His first aphorism is not often quoted in its entirety. When I first read it, I was struck by especially the last two words, “externals cooperate”. It makes me think that perhaps doctoring a few thousand years ago might have been a lot like today. We aren’t the first physicians to deal with demands beyond those of the clinical circumstances, the patient and his or her family.

I can only imagine who the externals were in Hippocrates’ time, but I am thoroughly familiar with who they are today: They are insurance company doctors and executives, pharmacy benefit managers and others, who say yes or no to our diagnostic and treatment plans. They are the ghosts in the exam room when patients and doctors try to make plans together.

The phrase “experience perilous” seems to imply that the gaining of experience is fraught with danger, but an alternate interpretation is that relying only on one’s own experience can be misleading. Hippocrates often emphasized the need to apply the known science to the practice of medicine.

The central point is that it takes time and effort to learn the art of medicine, which is sometimes glossed over in our fast moving society.

The volume of known science has obviously multiplied since Hippocrates’ time, and we can each know only a small fraction of it. But with all the available information now instantly searchable, we can become dangerous to our patients if we apply things without knowing them well through education and experience.

So, in the spirit of Hippocrates:

The artful practice of medicine requires understanding of the science, technical mastery of the craft, and wisdom


Facts can be learned by anyone; experience is earned through years of practice; wisdom is granted to us only if our hearts and minds are open, in our practice of medicine, and in our lives.

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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