I was asked today why I spent so much time talking to my patients and not as much time examining them.
I was taught long ago that the history portion of a patient visit provides 90% of the information needed to arrive at a diagnosis and that the physical examination and the tests used to confirm the diagnosis account for 10% of the encounter. I still believe that this is true. I must admit that I cheat a little.
The way my office is designed, the waiting room is about forty feet away from my office. There are a couple of turns along the way, and since I usually escort patients from the waiting room to my office, I get to see how they get out of the chair in the waiting room, I observe the way they take their first steps and how steady their gait and balance are that day, as well, I smell them as I greet them with a hug. To most people, this wouldn't add up to much, but in those few instants, I have already determined whether or not they have a fever, if they have a streptococcal infection or diabetes, as well as the state of their hygiene. All of this and they haven't even embarked on the long walk to my office. This dynamic assessment of patients is more accurate and informative than the traditional disrobed patient waiting in an examination room. As we walk to my office, we talk and I assess the state of their mood, and vigor. Can they keep up with me or am I steps ahead of them? Do they stop at the corner to negotiate the turn or are they swift? Do they bob from side to side or do they use the wall to steady their steps? Are their hips level as they walk or are they favoring a particular side, or joint? Are they dragging their feet, or flapping them? You get the idea... By the time we sit down, I already have a pretty good general assessment of how they look and must feel. My first question: How are you doing?, is almost redundant, but it opens the conversation and allows the patient to fill in the blanks. While we talk, I study the rate of their speech, the tone and quality of their voice, their choice of words, and whether or not they are using first choice words or the ones that come first, because they are blanking on the word they actually want to use. Are the hands shaking, is the face quivering? Are they fidgety, anxious? Is their complexion normal or sallow? Are the conjunctiva icteric (jaundiced)?
There is so much information I gather during the talking part of the visit, that the examination is an opportunity to take a closer look at things I suspect are going on and to reassure the patient that I am actually doing something.
I ask my patients not to wear perfume prior to seeing me, and I would advise you to do the same. Along the same line, for those of you who still smoke, it's a good idea to try to not smoke prior to your visit as the cigarette smell on your clothes is overwhelming and distracting.
Lastly, I order the fewest tests possible, and this tends to bother some patients. I use tests to confirm or rule out what I already suspect. If I can't figure out what I am looking for; that's the time to send the patient to someone smarter than me.