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Times Have Changed

Spring is upon us. Most people have moved their clocks up an hour; spring forward, fall back. Time has a habit of sneaking up on us. No matter what our distractions are, we feel time slip through our hands like grains of sand; each grain contributes to a mighty sand castle, each second adds to a significant memory. Time never stands still even though we might.
 
There is never enough time to do everything we need to accomplish. Regardless of our intentions, time is a dimension that we cannot control. We rarely schedule our lives fully appreciating the correct length of time it takes to interact with others or nature. Everything takes longer than we anticipate. Whenever we make adjustments, we frequently have to re-adjust to stay on track. I think it is safe to say that I never stay on track since I never know what track I’ll be on at any given time.
 
One aspect I have noticed recently is that people are keenly aware of the time a physician spends with them as they reveal their signs and symptoms. What astonishes me is the lack of time physicians as a whole spend with patients trying to decipher clinical clues to diagnose and treat an illness. I recently discovered that the medical practice industry on average allocates seven minutes of clinical physician time per patient, including vital sign measurements taken by a nurse or medical assistant. Time flies when a physician or physician extender examines someone.
 
I had the honor of caring for a young woman last week who had an incredibly complex medical problem. Putting the history down was extremely difficult because she was uncertain of her answers to many of my questions. The chronology of an unfolding illness is more important than any blood test or imaging study. How things become unraveled and the time in which they occur reveal valuable information. It took two hours to tease through an illness which had multiple tentacles and several rabbit holes.
 
The traditional questions of when, where, why, what and how are all pertinent to a patient’s history. Knowing what precipitates or improves a symptom is also crucial in deciphering the code of a medical illness. Human illness typically follows natural patterns since the body has a few known responses to alterations in health. Identifying the iteration is key to finding a solution to correct the underlying equation of disturbed physiology. The problem in medical practice today is that we have become too accustomed to blood and image testing. Many functional illnesses are not related to alterations in blood or image tests. A patient can be profoundly ill, and their clinical blood testing and imaging study results be square within the normal reference ranges provided by the laboratory.
 
The most frustrating aspect of patient evaluation is that humans are visual animals; eighty percent or more of our cognitive problem-solving activity ties to our visual cortex and other neuro-associative areas of the brain directly. What we see is what we get. The problem is that all humans project ideas and constructs into what we visualize based on our past experiences. Physicians are no different. Medical schools and residency training programs do not retrain a physician to ignore their personal bias when evaluating a patient, especially if they do not look or act ill - whatever that means. Patients tend to clean-up and look presentable when they visit a healthcare provider.
How many times has a physician said, “You don’t look ill” to one of my patients?
 
Once a medical practitioner’s lips utter those words or something similar, the evaluation is over. How one looks to a physician will establish the basis of the truthfulness of the patient’s words. If a patient appears good but reports feeling bad, most times the physician will typically project healthiness into an otherwise unhealthy person, ignoring the patient’s symptoms and allowing the practitioner to dismiss the entire illness claim. It’s much easier to dismiss a complex medical problem than to dig into it when you have only seven minutes to examine a patient thoroughly, come up with a diagnosis and render a standard of care therapy.
    
Then there is the referral to a specialist card when there is the slightest chance that the practitioner can get away with kicking the can down the road. Specialists also have a limited amount of time to examine patients so their evaluations tend to be laser focused. The specialist has a well-defined number of tools in their tool bel. Seldom do they expand their ideas past their self-defined practice boundaries. These boundaries are called the scope of practice. If a cardiologist examines a patient for shortness-of-breath and all of their heart test results are within reasonable limits, they may refer the patient to a hospital or a pulmonologist to perform pulmonary function tests to rule in or out lung disease. When specialists start pulling out the referral to a specialist card, the patient is in for a medical specialty journey of the first order. Many of these specialists do not communicate with one another other than sending a brief letter describing the testing results and that the patient does not have a medical problem for which their specialty is caring. I have witnessed patients having at least four or five specialist evaluations without getting a reliable diagnosis for their illness.
 
Mayo Clinic prides themselves in shuttling people with mysterious illnesses around to numerous specialists, rendering a report which includes excerpts of each specialist’s report. Mayo has a “quarterback” doctor who coordinates the patient evaluation activity. Seldom do they find a diagnosis of unidentified fatigue or joint pains because the patient’s physicians already performed the same testing as Mayo without any abnormality identified. Repeating the same clinical tests is just repeating the same tests. Mayo physicians have more time to spend with patients than non-Mayo physicians.
 
When I attended medical school in the seventies, I was taught to have a relationship with my patients to appreciate the impact of their illness on their lives fully. I was also trained to diagnose a disease before sending someone to a specialist for consultation. At that time, specialists provided treatment options to both patient and the physician who originated the referral. It was up to the primary care physician to institute the recommended treatment and follow the patient for any complications or untoward side effects — my how times have changed.
 
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