$200,000 Question

How do you keep from losing patience with patients? One of the most irritating things for me is to have a patient jump straight from their chief complaint, to the assesment and plan. For those of you who are non-md, do, rn, lpn, pa, np, ms1, ms2, ms3, ms4, emt, emt-i, emt-p, etc, the cheif complaint (CC) and assessment and plan (A&P) are portions of a rigidly structured medical encounter designed to facilitate communication and consistant recording of medical information among providors. The chief complaint is the very first item…what brought the patient into the department. The assesment & plan is the very last portion of the encounter. The assesment is the phyisicians current working diagnosis with alternate differentials (other explanations of the current condition of the patient) along with a plan of what tests, studies, referrals or interventions that the patient should undergo in order to fix/heal/diagnose/repair the problem.

The assesement and plan is the culmination of the physicians educated medical knowledge as applied to each individual patient, combined with astute physical exam information (do they have rales? ronchi? wheezes? egophony? whispered pectriloquy?) neatly summarized in an elegant, simple sentance or two. It takes not only years of advanced schooling, but many more years of clinical training and independant practice to perfect the art of a beautiful and eloquent assessment and plan…if anyone ever perfects it. But we practice these skills every day with every patient encounter.

So now imagine, you are the physician, in any stage of training, presented with the following patient encounter:

Doctor: “What brings you to the emergency department today?”

Patient: “I’m having pain in my ribs, identical to the pain I had three weeks ago. Do you think that I have fluid on my lungs? Will I need another antibiotic?”

Did you catch that? Did you see how the patient jumped straight from the chief complaint (rib pain) to the assesment (fluid on her lungs) and plan (antibiotics)? She skipped everything inbetween! All those other structured elements that we treasure so highly as providing invaluable information and clues to the patients current problem. Perhaps she had fluid a week ago, but today it’s something different. She didn’t even give us a chance to ask questions about the interim.

OK, try this one on your own:

You: “Tell me what brings you into the emergency department today?”

Patient: “Well, I ripped my rotator cuff all up last thursday. I could feel it ripping everytime I did something.”

You: “Well, why did you continue to use it if you felt things ripping?

Patient: “Well, I don’t know. I can’t keep still.” Pause. “I’m definately going to need surgery, though, right?”

Did you catch the elements there? Chief complaint “ripped up shoulder” (chief complaints are always in the patient’s own words). Assessment and Plan…ripped up shoulder requiring surgery. Don’t feel bad if you didn’t quite get this one exactly…you see, the patients chief complaint, was actually an assessment! She put the last element first! BAD PATIENT! You see, it’s so difficult to teach patients how to properly present themselves, because we only get one chance to see them! They have no incentive to learn how to start from the beginning of their problem, and patiently wait for me to ruminate on various diagnoses, options, treatments, re-examinations and results before presenting to them, my $200,000 assessment and plan. (that’s how much it costs to really learn how to do one right).

I guess I just need to enroll my patients in some continuing education classess until they get things right. It would make my job a lot easier.

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