Like most physicians, I feel extremely rushed during the course of my work day. And every day I am tempted to cut corners to get my documentation done. The “if you didn’t document it, it didn’t happen” mantra has been beaten into us, and we have become enslaved to the quantitative. It’s tempting to rush through physical exams, assuming that if there’s anything “really bad” going on with the patient, some lab test or imaging study will eventually uncover it. Just swoop in, listen to the anterior chest wall, ask if there’s any new pain, and dash off to the next hospital bed. Then we construct a 5-page progress note in the EMR, describing the encounter, our assessment, and plan of care.
Focused physical exams have their place in follow up care, but I strongly urge us all to reconsider skimping on our exams. A fine-toothed comb should be used in any first-time meeting – because so much can be missed as we scurry about. Some examples of things I discovered during careful examination:
1. A pulsatile abdominal mass in a woman being worked up for dizziness.
2. New slurred speech in an edentulous gentleman with poorly controlled hypertension.
3. A stump abscess in a 2-year-old leg amputation.
4. A bullet lodged in the scrotum.
5. Countless stage 1 sacral decubitus and heel ulcers.
7. Rashes that were bothering the patient for years but had not previously been addressed and cured.
8. Early cellulitis from IV site.
9. Deep venous thrombosis of the calf.
10. New onset atrial fibrillation.
13. Peripheral neuropathies of various kinds.
14. Lateral medullary syndrome.
15. Surgical scars of all stripes – indicating previous pathology and missing organs of varying importance.
16. Normal pressure hydrocephalus in a patient who had been operated on for spinal stenosis/scoliosis.
17. Parkinson’s Disease in a patient with a fractured hip.
18. Shingles in a person with eye pain.
19. Aortic stenosis in a woman with dizziness.
20. Pleural effusions in a man complaining of anxiety.
Oftentimes I don’t find anything new and exciting that is not already a part of the patient’s medical record. But a curious thing happened to me the other day that made me reflect on the importance of the physical exam. After a careful review of a complex patient’s history, I discussed every scar and “abnormality” I discovered as I did a thorough head-to-toe review of his physical presentation. His aging body revealed more than he had remembered to say… and as our exam drew to a close, he reached out and offered me a fist-bump.
It was charming and unexpected – but made me realize the true importance of the thorough exam. I had gotten to know him in the process, I had earned his trust, and we had built the kind of therapeutic relationship upon which good healthcare is based. No EMR documentation effort was worth missing out on this interaction.
You may not uncover a new diagnosis on each physical exam, but you can gain something just as important. The confidence and respect of the patient.
People's Choice Winning Idea: NephroZip
It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately, one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors and had the courage to tackle the problem head-on. Three years ago, Avik Som organized “Problem Day” at his medical school (Washington University School of Medicine in St. Louis, MO) and invited his professors to an unrestricted “open mic” venting session.
Representatives from the departments of surgery, medicine, pediatrics and neurology attended. They described their frustrations and day-to-day struggles with the students for 3 hours straight. After decades of service to suffering patients, it was the first time that anyone had asked them to share their own stories.
And borne out of this collective catharsis was IDEA Labs (a 501c3 ) – a student-driven movement to tackle clinician problems with fresh ideas and the energy of youth. I attended the third annual “DemoDay” (also known as “Solution Day”) presentations in St. Louis this week and was amazed by the breadth and depth of the student solutions to specific clinical problems. From plastic ties to hasten renal surgical procedures to energy efficiency units for hospital HVAC systems – the ideas spanned many technical knowledge domains, and investors in the audience paid rapt attention.
This year’s first-place winning idea was the Cystoview adaptor. Bladder scopes (or cystoscopes) represent a surprising 0.5% of Medicare’s total annual expenditures. Yet they still rely on old analogue technology and their images are difficult to share and transfer. The Cystoview device converts any cystocscope from analogue to digital, and images can be uploaded anywhere – from a desktop computer to a smart phone. Once collected, digital images can be mapped and reconstructed into a 3-D bladder scan so that surgeons can plan to more effective tumor resections. In addition, having the cystoscopes go wireless reduces the risk of infection associated with cords dragging across surgical fields.
IDEA Labs is unusual for several reasons. First, it was designed as a joint venture between professional schools at Washington University – Avik Som wanted to draw talent from Engineering, Business, Law, and Sciences to create multi-disciplinary student teams. The cross-pollination of student ideas can lead to some especially creative solutions.
Second, students retain 100% of the intellectual property associated with their solutions. So whether they design a specialized lumbar puncture chair, digital cystoscopy device, wheelchair storage mechanism, or new blood test for cancer, they are responsible for pitching their idea to angel investors and creating a business plan that will bring their ideas to market.
Third, IDEA Labs is student-driven, and therefore agile and independent from the administrative and political hurdles that can slow down innovation at academic medical centers.
Last year IDEA Labs students raised $300K in venture capital funding for their ideas. This year, they raised $1.5M. They are also actively franchising their student innovation model to other schools across the country.
Ramin Lalezari is a second year medical student and Director of Recruitment for IDEA Labs’ Executive Board. He is also an American Resident Project fellow (an organization that seeks out promising young medical students and residents and supports their writing talent – they also sponsored DemoDay this year). I got the chance to catch up with him at DemoDay. He described how he got involved with the project as a first year student, and worked with a team of engineers to design a system that detected pre-syncope in hospitalized patients, reducing the risk of possible falls.
“When I heard that medicine lags 50 years behind technology, I was horrified. Why do we still have pagers and fax machines?” huffed Lalezari. “We must do better. Students themselves will drive technology and innovation. We are going to build a network of incubators across the U.S., using telemedicine when appropriate. If a student in Los Angeles is passionate about solving a urology problem with engineers in St. Louis, then we will facilitate it. The student project manager pitches his idea, and students nationwide can sign up to help. Some of these design ideas are going to change the face of medicine. That’s our end game.”
I asked Lalezari if IDEA Labs would draw students away from practicing clinical medicine.
“There is no doubt that these projects require a time commitment. A few teams have disbanded due to the overwhelming burden of studying for exams. So some are quitting IDEA Labs. On the other hand, I’ve heard of some students who become so invested in their ideas that they talk about making a career out of it.”
“Are other medical schools developing their own IDEA Labs model for entrepreneurship?” I asked.
“There are 24-hr ‘hackathon’ models out there, and senior design projects that are formalized courses. IDEA Labs projects are 9 months long, with mentor-guided progress reports every 2 months. Most schools foster entrepreneurship from the top down – administrators and professors drive the ideas and the schools retain the intellectual property. I think that the bottom up approach resonates much more strongly with students.”
IDEA Labs may have turned the long-entrenched apprenticeship model of healthcare innovation on its head. No longer are students vying for the honor of supporting the design ideas of senior physicians in unpaid or underpaid internships. They are identifying problems and solving them in teams of peers without the hierarchy imposed by academic-driven projects. They have leveled the playing field and stand to gain a lot more from their hard work than ever before.
Although medicine may still be a dinosaur when it comes to technology adoption and innovation, the IDEA Labs students are replacing the soloist T. Rexes with team-working Raptors. And that represents a true leap forward in the evolution of healthcare.
***Demo Day was sponsored by The American Resident Project and J&J Innovation. For more information about how to get your school involved with IDEA Labs, please contact firstname.lastname@example.org.
Popular TV doctor, Gregory House’s favorite adage about patients is: “everybody lies.” I used to believe that this was a cynical and inaccurate statement, but I had to revisit it recently when faced with a patient whose signs and symptoms were consistent with a diagnosis that she vehemently denied.
A young woman was admitted to my rehab unit with brain damage of unclear cause. She adamantly denied drug or alcohol use, and I couldn’t help but wonder if she was suffering from a genetic or autoimmune disorder that the academic neurology team had somehow overlooked. I had recently read the New York Times best-seller, Brain on Fire and feared that I would be like one of those dismissive physicians who missed the author’s unusual diagnosis and nearly killed her from their inaction.
But staring me in the face were the specific physical manifestations of drug and alcohol abuse, though her urine toxicology screen proved she hadn’t used in the very recent past. I asked her again and again if she recalled any exposure to them – probing for an admission of even a small amount of recreational use. She remained adamant. An exhaustive work up had in fact revealed some vitamin deficiencies, the only hard evidence of anything that could explain her very real and devastating impairments. This was not a case of faking symptoms – at least I was sure of that much. Yet her situation continued to haunt me, because until she came clean about the cause of her condition, lingering doubt would drive me to continue the “million dollar work up.”
And for this young and desperately lonely person, the “million dollar work up” may have been her only chance at experiencing ongoing concern for her well being from others. If she admitted to drug use, then the only people who seemed to care about her (sadly, even if it was mostly because she could make a “great case for Grand Rounds”) would probably turn their backs. With the mystery solved, this fascinating neurological conundrum would become a garden variety drug abuser. A person who was, perhaps, not so much a victim as a perpetrator of their own condition.
I don’t believe that those whose conditions are contributed to by their behaviors receive poorer medical care (consider the smoker with lung cancer, or the person with multiple fractures from a bridge-jump suicide attempt – their quality of care will be similar to non-smokers with lung cancer or people with orthopedic needs from a motor vehicle accident). But there may be a subtle and unspoken judgmental attitude held by some of their caregivers and providers.
Fellow friend and blogger, Kerri Morrone Sparling suggests that fear of judgment, and the guilt and shame associated with self-induced harm, are the main reasons why people with diabetes may not come clean to their endocrinologists about their eating and exercise habits. She writes,
Finding enough confidence in myself to admit my shortcomings to my doctor, who I aim to impress with my efforts, was a tall order. For me, it took finding an endocrinologist I trusted with the truth, including the parts of the truth that weren’t so pretty. I know the best doctor for me is one who cares about my emotional response to diabetes, as well as my physical response. It took some trial-and-error, but eventually I found an endo who I felt didn’t judge, but listened and helped me find reasonable solutions to my problems with “reasonable” defined as something I would actually follow through on. Instead of a blanket response of “Do everything. Try harder,” my endo helps me build off of small successes in pursuit of better outcomes.
So patients lie to their doctors because they don’t want to be abandoned, judged, or shamed. And until they are quite certain that this will not happen to them, they are likely to continue withholding information from those who are ostensibly trying to help. The problem of lying does not rest squarely on the shoulders of patients – it is also the responsibility of physicians to make it safe for them to tell the truth. They will commit to honesty when we commit to compassion.
As I look back at my interactions with the young woman with the “mystery” illness, it is not so much the fear of missing the right diagnosis that haunts me now. It is that I did not make her feel safe enough to tell me the truth. In the end, the “million dollar work up” offered her little value for the cost and used up precious healthcare resources.
What she needed was a safe place to live, a supportive environment, a program for drug counseling, and job training for those with disabilities. I missed out on really helping this patient because I was more comfortable with searching for a rare diagnosis than pursuing treatment for the all-too-common, nebulous cycle of social ills that poverty, drugs and abuse cause. Maybe I wanted to believe her lie because at least then there was a chance I could fix her?
As it turns out, I was as invested in her lie as she was – we just had different reasons for it. While she did not want to be abandoned or shamed, I did not want to have to face the fact that I had very little to offer her.
Dr. House was right – under certain circumstances, patients are likely to lie. The other side of the coin, though rarely discussed, is that sometimes doctors are complicit in keeping those lies going.