Wednesday, July 28, 2010

Where Have the Patient Interview and Physical Exam Gone?

“No one cares what you find on physical exam; it’s what the tests show,” Dr. Lisa Sanders said. “And yet it’s clear the physical exam has important things to tell us. It can direct where we look. It can tell us – show us in a very real way – what’s going on.”
By Karen Thurston Chavez

My son’s last EKG scared me witless. It spit out its graph paper with its squiggly red lines, and along the diagnoses listed across the top: “possible Long QT syndrome.” (Long QT syndrome is a heart rhythm disorder that can potentially cause fast, chaotic heartbeats.)

I knew enough about Long QT to know it’s a serious and potentially fatal. I know my son, William, has scimitar syndrome/partial anomalous pulmonary venous return, along with mild right ventricular hypertrophy and a mild narrowing of his right pulmonary artery, but Long QT syndrome?

I waited anxiously for our pediatric cardiologist Dr. Jay Fricker to arrive in the exam room and halt my increasing panic. And he did – in his thoughtful and methodical way in his calm and soothing voice.

That cardiology checkup changed the way I think about my family’s physicians – all of them: our pediatric cardiologist, heart surgeon, pulmonologist, pediatrician, family internist, urgent care physicians, psychiatrist, general surgeon, radiologist and all of our nurses.

I pay far more attention to how much time a doctor spends interviewing and examining me or my children than I do on what kind of diagnostic test he or she might suggest or order.

Thank you, Dr. Fricker. Our pediatric cardiology appointment went a little like this:

“Dr. Fricker, I looked at William’s EKG report. What does that mean? It says Long QT syndrome. I know what it is, but why does it say it’s a possible diagnosis?

Dr. Fricker gave me his calm, reassuring smile. “Ah. Diagnostic tests. Do you ever listen to NPR?”

“Yes,” I answered, wondering what in the world this had to do with the EKG report.

“Did you hear the interview with Dr. Lisa Sanders?” he asked.

“No,” I confessed, wishing he’d get to his point!

Dr. Fricker explained: “She’s the real doctor behind the TV show 'House.' She talked a lot about how we, doctors, don’t spend enough time talking and listening to our patients and spend too much running diagnostics. We’ve come to rely too much on tests – blood tests, X-rays, EKGs, echos.

“You’re an established patient now,” Dr. Fricker continued, “but technically, I should have come in here and talked to you first, asked how William’s doing, how his activity levels are, appetite, how you feel he’s doing. Instead, we did an ultrasound and an EKG first – an EKG that has shown you a report that lists a potentially serious problem.”

“So why would it say William could have Long QT?” I asked him.

He didn’t use these exact words, but Dr. Fricker’s explanation boiled down to this: Some EKG machines don’t provide possible diagnoses; some machines do. And with the machines that do, the possibilities may or may not be correct because it’s just a machine using some sort of a generic formula to determine various possible diagnoses.

William’s EKGs have never been normal. Even after corrective congenital heart surgery, he still has abnormal EKGs. The day of his cardiology checkup, the EKG machine read William’s quirky heartbeat and decided he might have Long QT syndrome.

Dr. Fricker read the other possible diagnosis on the EKG strip: right ventricular hypertrophy. That, he said, was probably correct. The right side of William’s heart worked hard those first 27 months of his life, and it still hasn’t returned, and may never return, to a normal size. Perhaps William’s right ventricle has been thicker than normal since he was born.

Dr. Fricker spent a lot of time with us, asking about William’s appetite, any unusual situations, fatigue, changes in activity levels. How did I feel William was doing? Dr. Fricker did his own physical exam. He talked to William, and asked him how he was feeling, whether he played any sports, what he eats.

“William, do you like pizza?” Dr. Fricker asked.

“Yes,” William answered.

“Well. Eat more of it. Let’s see if we can put some weight on you,” Dr. Fricker said, and smiled. “What about ice cream. Do you like ice cream?”

“I love ice cream!” William replied.

“Eat more of that, too!” Dr. Fricker said. “Do you hear that Mom? William should eat a lot more pizza and ice cream.” We all laughed.

Dr. Fricker told us more about the interview he’d recently heard on NPR with Dr. Lisa Sanders. In that interview, show host Dave Davies talked to Dr. Sanders about the lost art of the patient interview, and the lost science of the physical exam.

Dr. Sanders said she believes the physical exam is dead.

“We’re taught the physical exam in medical school, but it doesn’t take long for you to realize … no one cares what you find on physical exam; it’s what the tests show. And yet it’s clear, the physical exam has important things to tell us. It can direct where we look. It can tell us – show us in a very real way – what’s going on.”

Doctors don’t listen as well as they should, Dr. Sanders said. “…Shame on us. Because it’s been known that the patient is the source of the information that … up to 90 percent of the time, will give us the answer to the questions: What’s going on? What does this patient have?

“But we don’t listen to patients,” she said.

Amen, Dr. Sanders. I can attest to that. William’s first pediatrician was a terrible listener. No matter what ailment William may have had, that pediatrician always traced it back to germs at daycare. Apparently, there was no other reasonable explanation for William’s often-serious illnesses.

Ever since that cardiology visit with Dr. Fricker, I have paid closer and closer attention to how health-care professionals approach us during our appointments.

At Shands Children’s Medical Plaza in Gainesville, where we go for our heart and lung checkups, 97 percent of the time, we are thoroughly interviewed, nurses and doctors perform complete and necessary diagnostic screenings (height, weight, pulse oximetry, blood pressure, etc.), and we have echocardiograms, EKGs, pulmonary function tests and, sometimes, X-rays.

Doctors listen to William’s heart and lungs, while he sits and lays in various positions. They look in his ears, nose, mouth, eyes. Squeeze his hands, feet, fingers, toes. Mash on his belly, check his throat and neck. In the pulmonary clinic, they quiz him about his asthma medications – what he takes, how he takes it, and if he thinks it makes him breathe better.

At home in Tallahassee, our physicians are employed by Capital Health Plan and they run their practices similarly to the way Shands does. Thoroughly – with patient/parent interviews and physical exams first, with diagnostic tests (if necessary) next on the list.

It was this thoroughness through Capital Health Plan that finally led to William’s accurate diagnosis, after other physicians failed to listen or thoroughly examine our son.

Dr. Lisa Sanders’ NPR interview should be required listening for anyone who sees a medical professional, and everyone who is or wants to be a medical professional.

That cardiology appointment and listening to Sanders' interview has changed the way I approach our doctors’ visits.

If you are my doctor or my sons’ doctor, and you don’t talk to us and examine us and get a thorough patient history, then you better pull up a stool, grab your pen and paper and get comfortable. Because I’m going to give it to you anyway. We deserve nothing less.

Karen Thurston Chavez is founder and co-executive director of Broken Hearts of the Big Bend. Since her son’s initial two misdiagnoses and eventual correct diagnosis, Karen tries to stress to all parents the importance of advocating for your child’s health and your right to quality medical care by board-certified health-care professionals.


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