Today brought a patient with a not so unusual complaint to the office.  As is my usual approach, I let her tell me about it with as little interruption as possible.  The goal is to permit someone to tell their own story and to prompt only for details, nuances...I follow a scheme learned at the bedside 20 years ago from a "master" clinician...1) "Quality"- have the patient flesh out the nature and experience of the symptom,  2) "quantity" - How often, for how long, continuous or not? - 3) Bodily location- (patient defined, and confirm with physical findings) 4) Setting - when are the symptoms noted, when not,  what else is going on? 5)Chronology - How have symptoms progressed/changed  over time  6) Aggravating/alleviating factors? Anything that seems to help? anything that seems to make things worse 7) Associated manifestations? What else seems to be associated are there any other symptoms anywhere else?

Obviously very free form - very unstructured.  That approach still works brilliantly - I would NEVER have been able to definitively diagnose my patients clear endocrinological problem from her presenting neurological complaint had I been constrained to use a template based on the "Chief Complaint"....I'd be doing way too much talking - asking entirely wrong questions, and she'd have likely left the office for a non-needed radiologic procedure that would have failed to yield a diagnosis and been a waste of her time and money.  Instead she left the office with clear knowledge of what was wrong and a treatment plan.

Explain to me why templates are an improvement if they fail to yield a diagnosis?  If I am to use one then someone has to write one that is superior to my current ability to define the nature of the patient's problem.  So far I have been entirely underwhelmed.

Get up at 5:45 am, get to work by 7:30 am...

I try to keep people healthy, or restore their health if something is wrong. First step is always to define what is wrong- or what is going right. Sometimes this is easy, other times it's not obvious and takes a while. Second step is translation- it's my job to make something complex understandable. I try to evoke visual images- usually as you watch people's faces you can see the light of comprehension click on. Third step is to figure out what they can or will commit to- and figure out what the resistance is if they DON'T want to do something that would help them. Sometimes there are tough trade offs and I'd be hard pressed to say which alternative is best. Other times it's a no brainer, but (a usually under educated) zealot has created fear when the odds overwhelmingly favor benefit rather than harm. Other times it involves a life stye change that won't be so easy to achieve...(Like exercise is good - but time to exercise competes with all these other things we have to do everyday)...

At the end of the day I update records, then review results of lab tests, radiology reports, specialist reports, fill prescription refills, call people to explain their reports, track down reports I'm expecting, send reminders to folks when it's time to do check labs or see me again.  Search the literature for clues when the diagnosis is obscure - make a plan for the people seeing me the next day...review their charts to figure out what information might be needed to keep them well or sort out their concerns.  Some of this can be planned in advance - the rest depends on what is going on when they arrive.

Get home - (if early) by 7 pm- sometimes closer to 9 - eat, sleep, repeat...

Reflections on rapidly changing health care landscape:  More and more folks are thrown into the fraying safety net.  More and more budget cuts impact this net. Greedy insurance companies skim the cream, and leave the crumbs for those trying to actually deliver services.  The already wealthy, serving the wealthy can easily afford the expensive EHR records that can artificially produce data indicating quality is available only from the elite private practices. (Appears that no one seems to understand statistics and epidemiology well enough to see through the data manipulation.)

In a nut shell- If the very poor, illiterate, non-English speaking, and homeless population are systematically excluded from the denominator of the data presented, and only the health outcomes of the educated employed insured are presented - Imagine what an effective health care delivery system it will appear that you are a part of!

However when you look past the veneer and scrutinize the drivel that passes for medical history from these EHR's and the differential diagnostic mediocrity hiding under the multi box check lists - and then sit down with the (hand written) medical records of those of us who are still standing in the trenches with the afore mentioned "excluded" population, what you might realize is that better actual medicine is practiced without the dumbed down scripts of EHR.