Thursday, December 25, 2008

Pod's Point: What Does the Wall Street Journal Health Blog, Baylor and the New England Journal Teach About the Physical Examination?

Look hard down the hospital's hallways, around corners and beyond the doorways and you will begin to find them. Dimly lit rooms filled with flickering computer displays networked into the healthcare information systems. Every mg.% lab test, every mg. of drug, every datum of past medical history, every cc. of urine output, every explained and unexplained x-ray abnormality and everything ever written by any provider on every patient is there. The only thing that is missing?

That’s the topic of an interesting ‘Perspective’ by Abraham Verghese MD in this week’s New England Journal of Medicine. He says what is missing is not the patient, but the doctor: the thinking, breathing hands-on type of physician that personally asks about the symptoms and performs a thorough physical exam. Nowadays, what passes for physicians are really remote rushed informaticians who coordinate instead of care and document instead of treat. He points out that actually seeing the patient and touching one are becoming mere formalities.

Case in point? Check out this tongue in cheek posting in the Wall Street Journal Health Blog. While the aim of the post is to address the tiresome issue of the value of annual checkups, the picture displays an example of what concerns Dr. Verghese. Classic, well-performed checkups are supposed to involve a disrobed patient with a package of separate exams of each organ system including (but not limited to) the heart, the lungs and abdomen. Dr. Sadler of the Baylor University Medical Center, on the other hand, is using the classic “Pod’s Point” approach to the abbreviated pro forma examination.

“Pod’s Point” is an inside joke among many physicians describing a spot to the left and below the sternum (breast bone). When a stethoscope is applied in that area, the time-pressed examiner can simultaneously hear the heart beat, the lung’s breath sounds and the gurgling from the abdominal cavity in a second or two. It is named after orthopedic specialists (orthopods or “pods”) who have a reputation for not bothering with time consuming or detailed physical examinations.

Pod’s Point has several advantages. Not only does it save time, it gives the harried physician a chance to symbolically display the use of the stethoscope, giving the patient the impression that actual healthcare is being rendered. By hearing heart, lung and intestinal sounds, the examiner can honestly document in the chart that the three organ systems are apparently normal. It also fulfills the minimal criteria of the performance of a patient examination. It can be used in any setting including the ICU, the emergency room or clinic and can be applied to any patient in any position (such as sitting up) and with or without any amount of clothing. Finally, it is reimbursed by all insurers. The only disadvantage is that subtle and important findings that could be key to the diagnosis and treatment of patients can be missed.

The Disease Management Care Blog believes “Pod’s Point” is a perfect answer for today’s rushed physicians who need to blow through the perfunctory examination so that they see the next patient and/or return to reading and entering data in the electronic health records. The DMCB salutes the WSJ Blog and Baylor for reminding us about the modern version of today’s practice of medicine.

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