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Sunday, October 13th 2013

The Time We Spend With Patient’s Isn’t A Disaster

A month ago an article in the Annals of Internal Medicine looked at the work day of medicine doctors in training. In the study medical interns were spending just 12% of their time with patients. The rest of the time was spent charting or entering orders or talking to other doctors or in didactics or in other non-direct patient care activities. Back in 1989 interns spent 20% of their time with patients.

The finding drew commentary from, amongst other online sources, Medrants and Dr. Pullen republished at Kevin, MD.

Decreased time with patients isn’t a good thing, but it is hardly a disaster. The smaller time with patients represents increased non-direct patient care requirements, such as documentation, as well as decreased reliance on the physical exam and patient history.

I’m going to argue that the history and physical exam have long been overvalued and the loss of focus on such, which is both a cause and consequence of the fact physicians spend less time with patients, cost nothing in terms of quality of care. Many aspects of the history and physical exam have remarkably poor reliability and reproducibility.

From Evidence Based Physical Diagnosis,

We can debate what represents good, rather than a poor, reproducibility on the margins but can probably all agree when interexaminer agreement on whether a pleural rub is present, when listening to a patient’s chest, is worse than chance that taking the time to auscultate for such a finding may hold little value. Similarly when the neurological examination of diabetics’ distal lower extremities shows that,

The interobserver reproducibility of the physical signs was moderate to poor

Or when clinicians can’t identify an S3 or S4 heart sound,

The overall interobserver agreement for the detection of either S4 or S3 was little better than chance alone

It is easy to imagine how nuanced physical exam findings (or lack thereof) could differ from one physician to another. Perhaps more surprisingly is of how little value the patient history has in some studies. In one study of a patient presenting with a stroke, neurologists asked to assess whether the patient had had a previously undiagnosed transient ischemic attack based on history alone achieved a kappa value of only 0.19.

Not to be dismissive completely of the physical exam and history. I’m not advocating a physician sitting as a computer and deciding the plan of care solely off what they read there. But in a world with ever improving diagnostic studies we shouldn’t bemoan the fact that the threshold has lowered for obtaining and relying on such. You still order such based on an initial exam and history but chide an order for a chest x-ray based on a history of suspicious sounding chest pain with only a limited physical exam. What does doing “A-to-E” or percussing add to the plan of care when the reliability of such results may be very low?

Nor is this a new phenomena. Many of the critical studies date to when the oldest commenting now would’ve been in training. The anecdote of the great clinician making reliable, consistent diagnoses off physical exam and history alone even in the most complex of cases is just that. The truth is, even if at greater cost, with the tools available today the current average clinician is a much better diagnostician than the average clinician of whatever yesteryear you want to cite.

Not that tests are perfect. Look at the interobserver kappa values for the various methods of diagnosing an intraarticular calcaneal fracture on x-ray. There are two things we can say about studies however. First, as the disease gets more “severe,” the reliability gets much better. That’s not something you can say in the studies, about something like a pleural rub.

For worst fracture grade we found good intraobserver (76–88%) and interobserver (74–88%) agreement, and excellent reliability with square-weighted kappa’s of 0.84–0.90 (intraobserver) and 0.84–0.94 (interobserver).

And, perhaps more importantly, as technology and computers get better, the reliability is improving.

Here’s what Dr. Watcher has to say on the time we spend with patients and the physical exam and history,

Even if we could create a new generation of expert physical examiners, would it be worth the time and trouble? I doubt it. When I was a medical student, I spent a couple of months at London’s Brompton Hospital, the UK’s premier lung disease specialty hospital. Brompton physicians lavished attention on the chest exam – elegantly listening for whispered pectoriloquy and egophany, percussing for dullness, and palpating for asymmetric chest excursions. Such exams often took 10 minutes. Ever the spoil-sport, around Minute 8, I found myself wondering why we just didn’t get a chest radiograph. Not because the ritual wasn’t engrossing – and yes, even “magical” at times – but because at some point, all of this elegance has to be weighed against cold-hearted considerations of accuracy, reliability, inter-observer consistency, and the cost of time.

[...]

In my zeal to bring physicians back into the patient’s room, I’d place 20% of the emphasis on performing and interpreting a good, thorough physical examination, and 80% on teaching and promoting superb communication skills…describing prognosis, discussing alternative treatments, determining the patient’s attitudes about end of life care, and apologizing for medical errors, to cite but a few examples. These are teachable skills that will never go out of style, skills whose value won’t be supplanted by PET scan results and graphs of trended ANCA levels. And, to me at least, they highlight the patient-as-person and physician-as-humanist more than sticking a tuning fork on a forehead ever could.

And I agree, if there’s a reason to bemoan a lack of patient contact it is such.

What’s odd however is that it’s my impression that such communication is not something physicians have ever been particularly good at. Even in a past where time with patients was more robust it seems, at least in tales, that paternalism hampered things like discussing treatment options or prognosis or end of life care. We continue, even in the era of patient empowerment, to perform such poorly in my experience. Communicating risks and complex treatment options is time consuming and a difficult skill and one that is poorly taught. But I’m not sure it was done better when the time spent with patients was more.

12% of your time with patients may be enough. It itself isn’t necessarily a disaster. Maybe we just need to focus on the important things more and stop beating the nuances of unreliable skills that are of ever decreasing importance into trainees.

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