Читать книгу The Slim Book of Health Pearls: The Complete Medical Examination - Sheldon Cohen M.D. M.D. - Страница 3

A complete medical examination includes a:

Medical history

Physical examination

Basic laboratory data

Risk factor analysis

Patients who have a good grasp of their personal medical data can prevent becoming a medical error statistic.

This book is for patients who want to take charge of their health and for members of the health professions interested in a review of the basics.

The book will speak to the patient and attempt to answer the questions asked over the years as the health care provider (physician, nurse, physician assistant) gathers a medical history and performs the physical examination. Patients need to know why the examiner asks specific questions, what benefits accrue from a thorough medical history, complete physical examination and, risk factor analysis, how the data is put together to arrive at the correct diagnose; and how this information will enable the prevention of medical errors.

The point needs repeating: involving the patient is the latest emphasis in the ongoing battle to prevent the medical errors that affect patients and healthcare workers alike. Being an educated patient is the best defense. When patients have a good grasp of their health problems, they become an important member of the team whose goal is to provide optimal and safe care.

Granted, this may all take time and presumes an ambulatory patient with the time to spend evaluating options. However, the time needed may not be available if the patient is involved in an acute life and death medical or surgical situation and is in an unfamiliar medical environment. In this instance, a written, or otherwise instantly retrievable summary of the medical history may be life saving. This is one reason why there is such a national impetus to promote electronic medical records, but until this day arrives, healthcare professionals must provide their patients with this important data in writing and not assume that when patients are told medical facts they will remembered for all time. Patients may soon forget what they learned in their doctor’s office.

In the absence of this critical, instantly retrievable medical information, and if a patient is unable to provide good clinical information, physicians, who are seeing a patient for the first time, will not be well-prepared for the very difficult and responsible position of having to provide care.

The book will discuss the important first step to take in health evaluation: a complete medical examination. Those educated to perform this vital examination include all physicians; but many super specialists, concentrating on their small slice of the body get rusty. Therefore, the responsibility falls to primary care physicians defined as internal medicine, pediatrics and family practice, and also a nurse and physician assistant.

The author will use the word “physician” when writing about the professional who captures a medical history and performs a physical examination. More often than not, the word physician will mean a doctor of medicine, either an M.D. or D.O., and, also in this case, a nurse and physician assistant.

Physicians first learn how to evaluate a patient in their early years of medical school. By the time budding physicians have graduated, they have had experience in taking medical histories and examining patients under close senior physician supervision. At this point, medical students have learned how to learn, and only a continuing experience will allow them to polish their craft. Nurses can receive master’s degree specialized education in the performance of the complete medical examination, and physician assistants can be educated to perform this function as well.

In the 1920’s the Metropolitan Life Insurance Company demonstrated that policyholders who underwent annual complete medical examinations lived longer than those who did not. On the strength of these statistics, the American Medical Association recommended periodic examinations of all healthy persons starting at age thirty-five. The general patient population has not yet received the benefit of this recommendation. Corporate executives have utilized the concept often, but the average person has failed to get a complete medical examination in any great numbers. What is the reason for this?

The most important physician-patient interaction occurs at the initial visit when patients present for a complete medical evaluation. This is time consuming and expensive. It stands to reason that a well taken medical history and full head-to-toe physical examination has a better chance of uncovering medical problems than an examination done in a hurried and cursory manner. However, the complaint I continue to hear from patients is that “The doctor had one foot in the door and one foot out.” As already mentioned, the average physician is very busy with acute and follow-up care, so they schedule their time to take care of the many patients seeking help. Therefore, the complete medical evaluation has suffered—and we are paying the price in unhappy patients, overworked physicians, medical errors and a malpractice crisis.

There are those who argue against the periodic complete medical examination, saying that it may not be cost effective in terms of the yield. They propose that the evaluation of patients who have no symptoms should be selective and based upon the age and sex of the patient. Major medical organizations in the United States and Canada have endorsed this approach. Most physicians do not dispute the wisdom of these endorsements, but cling to the belief that the complete medical examination is important, even though they bemoan the time constraints that make it difficult, and they cite the following reasons:

(1) Patients expect a complete medical examination.

(2) Physicians have had numerous experiences where the performance of the complete medical examination has elicited unexpected critical findings.

(3) A well-done complete medical examination enhances the physician-patient relationship. This must be emphasized; anything that yields a close relationship between patient and physician will promote understanding, rapport, and minimize medical errors.

(4) The complete medical examination offers the best opportunity to learn whether there are health risk factors that must be rectified and monitored. A full understanding of these risks will allow one to take charge of their health and play an important part in the prevention of medical errors.

(5) The complete medical examination provides medico-legal protection for patients and physicians. The structured complete medical examination can reduce lawsuits filed for this reason because there will be a greater likelihood of making the correct diagnosis.

Is there anything wrong with the complete medical examination? The major difficulty is its cost. It takes the physicians’ time and costs money, in most instances more than patients can afford and more than insurance is willing to pay. Because if its cost, the complete medical examination has fallen by the wayside for the average patient. Hence, the cornerstone of early detection and prevention, the complete medical examination and risk factor analysis, is often incomplete. In a medical office where the physician is so busy with acute and follow up care, here is where the well-educated nurse and physician assistant can be of great help.

As part of the complete medical examination, there are a large number of initial screening tests ordered. Invasive testing puts the patient at some risk. Therefore, the benefit to risk ratio test must be acceptable before performing these tests.

The complete medical examination does include some risk factor questions, however there is not enough information provided to allow correlation of the risk factor with the disease. Patients can take their own risk factor analysis (see The Slim Book of Health Pearls: Am I at Risk?) This book allows patients to take their own risk factor analysis, which then can be shared with their physician.

The best a physician can tell anyone after successful completion of the full examination is that, “The examination is normal in all its aspects.” There is a certain amount of reassurance in that statement, but inherent within it is that there is no guarantee. It is impossible to predict what the future holds, but following preventive and treatment recommendations will minimize the risks for death or disability. Patients understand this and are appreciative of the assurance that can come from a complete medical examination—if one can get a thorough one. This book will tell what it entails.

So, let us now go through a medical history and a complete physical examination just as an average physician does with medical students and patients in their private offices and in the hospital. The book will give clinical examples after each section. These examples, illustrating the history or physical examination point discussed, are from my own and colleagues experiences. There will also be some examples of unusual cases of great clinical and human interest.

Patients need to have a better understanding of:

The art and science of history taking

The technique of performing a thorough physical examination

Basic laboratory studies.

Risk factor analysis

The capturing of vital important written patient information kept in an accurate and understandable format available for instant recall.