If you want to understand why doctors sometimes complain about being doctors, see this page by the Happy Hospitalist on CPT coding for admission notes (one presumes he is happy because he enjoys this stuff). The gist of it is that the government has developed a complex set of rules and language by which health care systems can communicate what they have done to and for patients that they should be paid for, and that language is arcane, cumbersome, and bureaucratic. Benefit to patient care is indirect and comes from translating medical practice into codes that can fed into data sets which can later be mined by analysts for trends and such; that has to be balanced by the up front costs of mind-numbing and tedious documentation, billing, and coding that could be better spent at the bedside. Or golf course. Or …
Whatever. If you’ve ever tried to figure out what was going on with a patient by reviewing charts from before this era of forced thoroughness (or from old-school doctors who buck the system) you’ll know that part of the reason Medicare feels it has to nanny doctors is that has to – too frequently, we write shitty incomprehensible notes that only make sense to us at the time we write them. There are other plusses and minuses of this system and I’m obviously not going to get into it here.
But I’m going back on service next week and have been thinking a little bit about the physical exam. Depending on who you ask, it’s an art that’s dying, dead, or not dead enough. It’s not taught well in medical schools, which means the next generation of teachers doesn’t know how to teach it well, which means, etc. Also, why bother with a physical exam when we know that it’s often unreliable and, like, you’re going to get a chest x-ray and labs anyways, or maybe you’re going to learn how to use an echocardiogram probe that plugs into your iPhone, and with a thorough history those things are probably going to give you the answer you want.
My physical examination skills are not good, and haven’t gotten better with years of practice. At the same time, my skill at talking to patients and interpreting test results has improved dramatically. I can’t help but think that CPT codes have something to do with this.
Here are the requirements for a comprehensive physical exam: nine organ systems or body areas with two bullet points in each. There’s something about a complete single organ examination, but I don’t know anyone who knows what that means, and I’ve never read a chart where that’s been documented. For patients in the hospital, the expectation is to do this generally complete exam for every patient every day. That’s insanity, and it reduces the physical exam from a test to be applied rationally and as the situation warrants, to a list of boxes to check off according to rote habit. In fact, much of my physical exam course in medical school was precisely aimed at teaching us how to memorize and routinize the practice of doing a head-to-toe exam in as little time as possible. Again, crazy if your goal is to learn something about the patient and their disease. It’s helpful as performance art, maybe.
I had a cardiology attending once who said when he trained they used to try to guess the right atrial pressure by physical exam, and then verify it with a right heart cath at the bedside. That’s, well, fucked up. But also instructive. A cardiac examination with the goal of answering the question “what’s the right atrial pressure?” is more useful than one with the goal of answering the question “you say you have chest pain so can I learn something about it by putting a stethoscope on your chest for a few seconds?”
Anyways, I could say more here about false positives and false negatives, but instead I’m going use this space as a commitment strategy. I’m going to ignore CPT coding requirements for the forseeable future, and try to use the physical exam as a rational tool of investigation. I’m guessing it’s the only way to really teach myself how to do it well. Will use this blog to update on progress.