Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Wednesday, July 22, 2009

50-Year-Old White Female Blogger

Maurice over at the Bioethics Discussion Blog posted a recent take on an old issue: how much information to try and squeeze into that all-important "first line" of the history and physical. Should medical students be taught to include or exclude medically "extraneous" data like race, ethnicity, marital status, etc. in their case presentations? Like this:

45-year-old black female homemaker...
57-year-old married white male machinist...

74-year-old left-handed retired Asian math professor...

The argument is that aside from age and gender, all the other information about ethnicity, marital status and the like is not medically necessary. This is true. The big arguments, of course, center around race, with the presumption that certain diseases have certain racial predilections. This, of course, is also true and not true, in that race is recognized as more of a cultural construct and has much less biological significance than previously recognized, although certain conditions do indeed occur with greater frequency in persons of various genetic backgrounds.

Some other pieces of information are specialty-specific. Neurologists usually include handedness in their opening statement, because it is often germane to the conditions they encounter. Not always, of course; who cares what hand a migraineur writes with. Still, it is part of their schtick. It is also logical for Occupational Medicine notes to make prominent mention of the patient's occupation. So there are isolated instances where seemingly extraneous information becomes relevant.

The rest of the discussion centers on the perils of physicians pre-judging their patients, falling into stereotypical thinking on the basis of the descriptors included in the H & P's opening statement. I believe this fear is overblown. Hopefully doctors refrain from jumping to any prejudicial conclusions solely on the basis of the first words of a case presentation.

That said, I think the entire argument is moot.

The unspoken assumption when talking about teaching medical students "how to do a history and physical" is that there is a "right" way to do one, including a "correct" way to present one's findings to others. It is true that there is indeed a standardized format of sorts for an H&P which ought to be taught to medical students. It usually contains the following components:
  • Chief Complaint (CC)
  • History of Present Illness (HPI)
  • Past Medical History (PMH)
  • Family History (FH)
  • Social History (SH)
  • Review of Systems (ROS)
  • Exam
  • Lab, Imaging and other studies
  • Formulation or Assessment (diagnosis), and
  • Plan
The problem is that in real life (as students will learn their first day of their clinical studies) this format is extraordinarily context-dependent. Different sections of the history take on different significances depending on the patient's circumstances and the physician's specialty. Past medical history is usually nonexistent in infancy (aside from information about the pregnancy, labor, delivery and nursery course), and family history is immaterial after the age of 80. In essence, students have to learn a whole new H&P format with each rotation.

This is not wrong. One thing that bothered me in medical school was classmates who claimed that they had been taught to do the H&P a certain way, and by Gd that's the way they were going to do it. Um, no; when you're doing Obstetrics, it's not that important to determine what the patient's grandfather died from and whether or not she ever had her tonsils out. (Just try asking all your Review of Systems questions to someone in active labor and see how far you get.) The idea that the H&P for the initial presentation of an adult patient with a medical (as opposed to surgical) problem, as taught in medical school, is the only "right" way to do an H&P is inflexible and impractical. Similarly, the idea that "presenting the patient" is always done exactly the same, regardless of whom you are presenting the patient to (and the reason for the presentation) is nonsense.

Think of an H&P like a painting. There are many different kinds of paintings: still life, portrait, landscape, miniature, abstract, and so on. There are the basic artistic concepts of design, line, light, color, layout, but different kinds of paintings require emphasis on different principles. If you imagine all students beginning with an oil painting of a still life of a vase of flowers, how silly is it to think of them complaining that a landscape isn't a "real" painting. In our case, that internal medicine patient presenting for the first time with a new problem (as opposed to a patient in the ER, or a patient needing a pre-surgical evaluation, or a newborn, etc.) is the equivalent of the floral still life. Learning to recognize when that form is appropriate is half the battle.

In terms of presenting the patient, again, context reigns supreme. The formal version discussed by Maurice is designed for the presentation of a new patient to clinicians who do not already know the diagnosis. ie, a clinical puzzle, as seen in the New England Journal of Medicine and elsewhere. As third year medical students will quickly learn, that won't get you very far on morning rounds. "Hemicolectomy, post-op day three, afebrile, passing gas" is all they want to hear on surgery. "Mulitip at six centimeters an hour ago, comfortable with epidural" will do on Obstetrics. You get the idea.

After all that, though, in answer to Maurice's question, I'm going to come down on the side of more information in the opening statement rather than less. I'd love to hear something like, "58-year-old married female secretary who just dropped her last child off at college and started art lessons last week..." and here's why. It has to do with this quote from Sir William Osler:
"The good physician treats the disease; the great physician treats the patient who has the disease."
The more I know about the patient who has the disease, the better job I will be able to do caring for that patient. How better to get to know the patient than to describe him or her as fully as possible right from the start of the encounter. For those who worry about stereotyping, allow me to offer the following suggestion: ask the patient to describe him or herself, and then include the response in the opening statement. Like this:
This is a 50-year-old white female physician blogger with grown children and way too many animals at home who describes herself as "zaftig but generally healthy."
I don't treat diseases. I treat people, and because every person is different, I think it is better to err on the side of more description rather than less.


At Wed Jul 22, 05:32:00 PM, Anonymous Anonymous said...

One of my friends, who is an urology resident, always makes one patient the "patient of the day" and together with a medical student he takes at least twenty minutes to talk to the patient and go into his personal life and history. He always comes up with amazing and beautiful stories from his patients. It is a pity that in surgery we only have 5 to at most 10 minutes for each patient...

At Wed Jul 22, 06:37:00 PM, Blogger Maurice Bernstein, M.D. said...

Of course, I agree. There is much more in treating a patient than simply or not so simply treating the disease.

We are debating this "first line identifier" issue in the medical school where I teach since the advice to eliminate race and ethnicity in the first line of the history is to us long time teachers a major revision in what we teach. We've got to think about it. ..Maurice.

At Wed Jul 22, 07:13:00 PM, Anonymous Anonymous said...

I, personally, am ISTJ. Good to know you're ZBGH.


Kensington MD

At Wed Jul 22, 07:46:00 PM, Blogger Ambulance Driver said...

"Not always, of course; who cares what hand a migraineur writes with."

As long as it's the signature block on their AMA form or their discharge instructions, I'm pretty flexible.

--40-year-old crunchy on the outside with a soft nougat center paramedic currently sitting naked in a beanbag chair eating Cheetos while surfing porn.

Come to think of it, that would probably explain why my genitals are always orange when I wake up in the morning.

By Jove, you're right! Knowing more about the patient and including more in the description CAN be useful!

At Wed Jul 22, 08:05:00 PM, Blogger #1 Dinosaur said...

Okay, I take it back. Thanks to AD, I can officially say that there actually IS such a thing as too much information.

At Wed Jul 22, 08:10:00 PM, Anonymous Anonymous said...

This comment has been removed by a blog administrator.

At Thu Jul 23, 12:04:00 PM, Anonymous Anonymous said...

But when we're all using templated EMRS, complete sentences, chronological narrative and analytic synthesis of the history and physical will be worthless, won't they?

At Thu Jul 23, 01:40:00 PM, Blogger Hal Dall, MD said...


While the narrative and synthesis becomes worthless, all that extraneous detail becomes golden as it gives you a higher E&M code.

At Thu Jul 23, 05:11:00 PM, Anonymous Clinton said...

an exercise we did in my family medicine clerkship was to "describe [yourself] with one word." we had to come up with 10 words and it was really interesting what emerged...

medicine, male, asian, geek, [high school], student, scientist, blogger, etc. etc.

some people sounded like personal ads in the newspaper: funny smart single caucasian female seeks friendship

some people tossed in hobbies, friends and family.

everyone started off with the same basic descriptors and then bloomed into really interesting things. i think it'd be a fun exercise with patients -- and the ones who refuse automatically get labelled as "grumpy."

At Sat Jul 25, 10:12:00 AM, Blogger Larval Doctor said...

as a geneticist in training, I care a lot about ethnicity and very little about skin color. I was trained to ask my patients to identify the countries of origin of each grandparent and will report that in my identification statement (e.g. "This is a 14 year old female of mixed German-Irish-Kenyan and Korean descent without any Ashkenazi-Jewish ancestry") It's a mouthful to use on general medicine, but trying to associate skin color with disease is like trying to identify predilection to pediatric disease using height rather than age.

At Thu Jul 30, 10:35:00 AM, Blogger kennylin said...

I remember being a medical student at Bellevue Hospital in NYC and beginning countless presentations with "Patient is a XX year-old undomiciled male ..." I guess that sounded better than "homeless," or was more politically correct, anyway. Thanks for this thoughtful posting.


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