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I was about to enter an exam room to see my 30th patient of the day. “Dr. Wilkoff, her rapid strep test is negative.” Meredith is our newest PPS (patient placement specialist, a job category I invented several years ago), and she thought she was being helpful. But no one had told her that while one or two of my colleagues have asked their assistants to swab the throats of anyone complaining of sore throat, I prefer to do it myself after I have seen the patient.
There was nothing to be gained by holding my breath and turning purple. The water was over the dam. But now what was I going to do? The whole rhythm of this office visit would be thrown off. Like most people, I thrive on routine. When I am busy, routines and habits (good, bad, or ugly) help maintain my efficiency and sanity.
Of course, I have never sat down and written a script for my typical office visits, but over the years a standard plot pattern has evolved … a plot into which I weave as much drama as the scenario will allow. Each one-act play begins with an introduction during which I make a little small talk about the weather or comment on how well or poorly the Patriots or the Red Sox are doing.
Shifting to a more serious and thoughtful persona, I begin taking a history, scribbling illegibly, and sketching the painful body part. In most situations I am 94% confident that I know the diagnosis and have already begun developing my plan by the time I've heard the story. However, to build and maintain the suspense, I continue to contort my face to reflect curiosity and concern, and then I examine the patient.
In most cases I pause at the end of the exam and announce, “Let me do some more writing, and then we can talk about what might be going on and what we should do about it.” Occasionally, I add the apology that if I don't write things down immediately they will be forgotten. This is true, of course, but the real reason for this 60-second pause for documentation is that it will add even more suspense to the visit.
Hopefully, by the time I am ready to reveal my diagnosis, the patient is squirming with anticipation and will be more likely to accept without question my diagnosis of a simple URI requiring no specific treatment.
It is only in rare cases that my history and physical examination have not solidified the diagnosis. Then and only then is it time for some lab work. This may be an “old school” approach, but I think it is a tradition that serves us all well and not just because it can hype up the drama in a visit and make one feel professorial. Doing the lab work first devalues the two other components of a good clinical evaluation.
One need only look at a typical medical bill to see that the system already places a higher value on diagnostic studies (meaning lab and x-ray) than it does on a good history and physical. If we continue to request lab work and imaging studies before we have examined the patient, we will perpetuate this inequity.
Of course, there is always cost. Not infrequently the patient's chief complaint is so vague or so mangled by the person at the front desk that a routinely ordered preexamination lab or x-ray is unnecessary and makes no sense. I'm sure some of you must deal with orthopedists who demand MRIs before they examine certain patients. We're not talking the chump change of a rapid strep test here.
Finally, knowing the lab work before one examines the patient eliminates the intellectual gamesmanship that keeps me going. Looking at 50 sore throats a week can be a bit mind numbing. Guessing whether the rapid strep test is going to be positive or negative helps keep my head in the game.
I was about to enter an exam room to see my 30th patient of the day. “Dr. Wilkoff, her rapid strep test is negative.” Meredith is our newest PPS (patient placement specialist, a job category I invented several years ago), and she thought she was being helpful. But no one had told her that while one or two of my colleagues have asked their assistants to swab the throats of anyone complaining of sore throat, I prefer to do it myself after I have seen the patient.
There was nothing to be gained by holding my breath and turning purple. The water was over the dam. But now what was I going to do? The whole rhythm of this office visit would be thrown off. Like most people, I thrive on routine. When I am busy, routines and habits (good, bad, or ugly) help maintain my efficiency and sanity.
Of course, I have never sat down and written a script for my typical office visits, but over the years a standard plot pattern has evolved … a plot into which I weave as much drama as the scenario will allow. Each one-act play begins with an introduction during which I make a little small talk about the weather or comment on how well or poorly the Patriots or the Red Sox are doing.
Shifting to a more serious and thoughtful persona, I begin taking a history, scribbling illegibly, and sketching the painful body part. In most situations I am 94% confident that I know the diagnosis and have already begun developing my plan by the time I've heard the story. However, to build and maintain the suspense, I continue to contort my face to reflect curiosity and concern, and then I examine the patient.
In most cases I pause at the end of the exam and announce, “Let me do some more writing, and then we can talk about what might be going on and what we should do about it.” Occasionally, I add the apology that if I don't write things down immediately they will be forgotten. This is true, of course, but the real reason for this 60-second pause for documentation is that it will add even more suspense to the visit.
Hopefully, by the time I am ready to reveal my diagnosis, the patient is squirming with anticipation and will be more likely to accept without question my diagnosis of a simple URI requiring no specific treatment.
It is only in rare cases that my history and physical examination have not solidified the diagnosis. Then and only then is it time for some lab work. This may be an “old school” approach, but I think it is a tradition that serves us all well and not just because it can hype up the drama in a visit and make one feel professorial. Doing the lab work first devalues the two other components of a good clinical evaluation.
One need only look at a typical medical bill to see that the system already places a higher value on diagnostic studies (meaning lab and x-ray) than it does on a good history and physical. If we continue to request lab work and imaging studies before we have examined the patient, we will perpetuate this inequity.
Of course, there is always cost. Not infrequently the patient's chief complaint is so vague or so mangled by the person at the front desk that a routinely ordered preexamination lab or x-ray is unnecessary and makes no sense. I'm sure some of you must deal with orthopedists who demand MRIs before they examine certain patients. We're not talking the chump change of a rapid strep test here.
Finally, knowing the lab work before one examines the patient eliminates the intellectual gamesmanship that keeps me going. Looking at 50 sore throats a week can be a bit mind numbing. Guessing whether the rapid strep test is going to be positive or negative helps keep my head in the game.
I was about to enter an exam room to see my 30th patient of the day. “Dr. Wilkoff, her rapid strep test is negative.” Meredith is our newest PPS (patient placement specialist, a job category I invented several years ago), and she thought she was being helpful. But no one had told her that while one or two of my colleagues have asked their assistants to swab the throats of anyone complaining of sore throat, I prefer to do it myself after I have seen the patient.
There was nothing to be gained by holding my breath and turning purple. The water was over the dam. But now what was I going to do? The whole rhythm of this office visit would be thrown off. Like most people, I thrive on routine. When I am busy, routines and habits (good, bad, or ugly) help maintain my efficiency and sanity.
Of course, I have never sat down and written a script for my typical office visits, but over the years a standard plot pattern has evolved … a plot into which I weave as much drama as the scenario will allow. Each one-act play begins with an introduction during which I make a little small talk about the weather or comment on how well or poorly the Patriots or the Red Sox are doing.
Shifting to a more serious and thoughtful persona, I begin taking a history, scribbling illegibly, and sketching the painful body part. In most situations I am 94% confident that I know the diagnosis and have already begun developing my plan by the time I've heard the story. However, to build and maintain the suspense, I continue to contort my face to reflect curiosity and concern, and then I examine the patient.
In most cases I pause at the end of the exam and announce, “Let me do some more writing, and then we can talk about what might be going on and what we should do about it.” Occasionally, I add the apology that if I don't write things down immediately they will be forgotten. This is true, of course, but the real reason for this 60-second pause for documentation is that it will add even more suspense to the visit.
Hopefully, by the time I am ready to reveal my diagnosis, the patient is squirming with anticipation and will be more likely to accept without question my diagnosis of a simple URI requiring no specific treatment.
It is only in rare cases that my history and physical examination have not solidified the diagnosis. Then and only then is it time for some lab work. This may be an “old school” approach, but I think it is a tradition that serves us all well and not just because it can hype up the drama in a visit and make one feel professorial. Doing the lab work first devalues the two other components of a good clinical evaluation.
One need only look at a typical medical bill to see that the system already places a higher value on diagnostic studies (meaning lab and x-ray) than it does on a good history and physical. If we continue to request lab work and imaging studies before we have examined the patient, we will perpetuate this inequity.
Of course, there is always cost. Not infrequently the patient's chief complaint is so vague or so mangled by the person at the front desk that a routinely ordered preexamination lab or x-ray is unnecessary and makes no sense. I'm sure some of you must deal with orthopedists who demand MRIs before they examine certain patients. We're not talking the chump change of a rapid strep test here.
Finally, knowing the lab work before one examines the patient eliminates the intellectual gamesmanship that keeps me going. Looking at 50 sore throats a week can be a bit mind numbing. Guessing whether the rapid strep test is going to be positive or negative helps keep my head in the game.