Friday, January 20, 2012

Routine or rote?

I am reprinting one of my favorite columns, first posted here on April 26, 2007.

A story for all who have been through the multiple rounds of medical histories upon entering an emergency department.

A good friend found herself in a local ED with symptoms of appendicitis. The first medical history was taken by the triage nurse. Then, another nurse. Then, an intern. Then, a resident. Finally, the attending arrived, and he started the process again, writing while talking and making no eye contact.

By this time, my friend had memorized all the questions, and she figured she could speed up the process by anticipating the next questions and giving the answers in advance of their being asked. "Have you ever had abdominal surgery?" "Yes," she replied, and proceeding to the next as yet unasked questions, offered, "It was a complete hysterectomy, and it was three years ago."

Without pause, and without thinking, he said, "Is there any chance you are pregnant?"

She, feverish and in pain, raises up one elbow, looks directly into his eyes and says, "Either you are trying to introduce some levity into this situation, or that is the dumbest question you ever asked."

He turns deep red and leaves the room without another word.

Moral of the story: In a busy environment like an ED, it is all too easy for providers to go on "automatic pilot" and not really pay attention to what the patient is saying.


Jim said...

I understand why she was frustrated by answering the same questions over and over.

However, there is a much more dangerous trend IMCO.

Because of the advent of EHRs, it has become much easier to simply take the history from the prior note.

There are a lot of assumptions being made that can mislead clinicians.

I have encountered patients wrongly carrying diagnoses of developmental delay, breast cancer and even HIV across multiple notes due to an initial error in entry that was never confirmed in later documentation.

The copy forward feature of EHRs can also be dangerous because it will copy and paste outdated information and any changes are buried in a mess of distracting prose.

All in all, she should be happy they actually spoke to her. The next step is getting them to speak to one another.

BTW, when I was a chief resident, I know of at least one instance in which a third trimester pregnancy was diagnosed during a CT looking for appendicitis.

Anonymous said...

Jim, I don't know how old you are, but copying the previous history in the chart long predates EHR's. I used to see it happen in the paper chart all the time, especially from consultants who didn't want to bother to take a history. The only obstacle was being able to read the previous doc's handwriting!
However, the ability of computers to 'make things disappear' IS new and truly dangerous. It's as if they never were, so paper trails of errors are very difficult to follow now.

nonlocal MD

Pat said...

Many years ago my daughter, a high school student at the time, had a very similar experience with repetitive questions about her pain and history while being worked up for appendicitis at a prestigious hospital in Boston in the middle of the night.

When the intern started his questioning she asked if he could please look at the notes from the last doctor (the medical student) and give her something for the pain so she could sleep instead of going through all these questions for the 4th time again. Of course he refused and continued the questions. She was very polite until he finished, at which point she told him “YOU are a perfect example of medical waste!”