I don’t know if anyone had a chance to hear the interview on Fresh Air on NPR with Dr. Sandeep Jauhar about his recent book, Doctored: The Disillusionment of an American Physician. I found that I could easily relate to his perspectives on modern medicine. He discussed how patients increasingly are living with multiple chronic illnesses that require multiple sub-specialists; but that there is little time for coordination of that care, much less preventative care in an environment that wants primary care physicians to see patients every 10 minutes.
Dr. Jauhar talked about how, though physicians know there is a great need for primary care physicians, the payer model doesn’t support a system that forces physicians to see patients on the basis of volume, with less pay. That specialists who just “see patients” are not nearly as profitable as those who perform diagnostic tests, tests that he feels often take the place of thorough history taking and physical examination; that this excessive testing is in part due to a lack of time as well as defensive medicine, and also, to improved survivability from a financial perspective.
I heard this interview and vigorously agreed with his assertions, as I am sure you would too, if you take care of patients for a living. It made me remember and appreciate the lessons I was taught when in private practice in pulmonology, with Dr. Anthony Marinelli. He taught me so well that “the history and the physical gives you the answer.” He easily spent an hour with a new patient, doing an incredibly thorough history, walked the patient up 6 flights of stairs while monitoring the pulse oximetry or the peak flow, called every. single. primary care physician, went down to radiology (before images were instantaneously available) and reviewed every old chest X-ray a patient ever had, all in the quest for the diagnosis. He was a giant among physicians. His impact cannot be overstated.
But I, like all providers in our current jacked-up system, have developed habits that support the system, not the patient sometimes. What might be best for the patient is a conversation, not more narcotics, a “watch and wait,” not another consult, a plan to go home, not a plan for more misery in the setting of near certain terminal illness. An actual history and physical. Not a CT scan.
Tracy Cardin, ACNP-BC, SFHM is the Associate Director of Clinical Integration at Adfinitas Health and also serves on SHM’s Board of Directors. Prior to this, she was the Director of NP/PA Services for the University of Chicago and worked in private practice for a group of excellent pulmonologists/intensivists for over a decade. She has been a member of SHM for over ten years and has over twenty years of inpatient experience, which seems incredible as she cannot possibly be that old! Her interests include integration of NP/PA providers into hospital medicine groups and communication in difficult situations.
In her free time, she likes to run and lift, read and write and hang out on the front porch of her semi-restored Victorian house with her dear family and friends while drinking a fine glass of red wine and listening to whatever music suits her whimsy.