A colleague of mine saw two different specialists in another state for a serious problem. Both doctors told her they did not feel comfortable treating her, and both referred her to a very prominent specialist in Philadelphia. She asked me to accompany her, listen carefully and take notes.
We went to the office and were immediately told that the very recent x-rays she brought with her were “not adequate” and she had to have another set of images at this facility. She complied. We were then brought into an examination room and a resident examined her without disrobing her. The examination was very cursory and he did not visually inspect or palpate the area of concern. In addition, he failed to review her extensive medical history. He then gave her a series of diagnoses and said that he could refer her to additional specialists.
The attending physician then entered the room. He did not wash his hands and was accompanied by a young woman whom he failed to introduce to us. He also never asked the patient to disrobe, did an even more cursory examination and rattled off a series of diagnoses that were very different from the diagnoses given by the resident and the two referring physicians in another state.
When he left the room, my colleague was in tears. I asked the nurse if the attending physician could come back in and she said that he was busy seeing other patients. I told her that we would wait. After a few minutes, he returned to the room, obviously annoyed at being called back in and questioned. I told him that I was a physician and we were confused and read him back verbatim the resident’s series of diagnoses and his. He told us that he was the attending and the resident was only a resident.
I wish this experience were atypical, but, unfortunately, it is not. Let’s look at some of the more serious issues it raises.
First, why were the images repeated? This generated unnecessary costs and radiation exposure for the patient.
Second, why did we have to waste our time with the resident if his diagnoses and his history taking and physical examination skills were inadequate? I understand that it is critical that residents interact with patients as part of the learning process, however they need supervision, mentoring and feedback. If this does not occur, deficiencies in their skills will be perpetuated. Why did the resident provide us with a series of diagnoses without speaking to the attending physician?
Third, why did the attending physician not disrobe the patient, why did he do an extraordinarily inadequate history and physical exam, and why did he then demean his resident in front of the patient.
This episode illustrates many disturbing issues with our modern medical care. I loved my career in medicine and always prided myself on being an excellent clinician and taking the necessary time to do justice to every patient I encountered. However, I am depressed and disturbed at the way modern medicine is too often practiced. Most worrisome is my suspicion that the great cerebral teachers of medicine (those who relied on history and physical examination skills and who made extraordinary efforts to avoid “sins of omission”) have either retired or died and that the teachers of our new physicians are increasingly technocrats who were never themselves taught the art needed to make a good physician. This could become a self-perpetuating phenomenon.
Before we can truly reform health care, the system must heal itself.
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