motivations for the right dx

Goodson, William, M.D. GoodsoW at CPMCRI.ORG
Thu Jan 23 05:05:53 UTC 2014

Hi Victoria,

You have identified what should be the primary issue, "we the patients" whereas Karen has identified the pressure on the other side to do more with less in less time.

There is a lot of talk of patient satisfaction surveys, but these focus more on who smiles the most. 

Since doctors are graded on the outcomes, for example control of Hba1c in diabetics or BP in people with hypertension, perhaps patients should complete a post office visit survey with questions like:
1.  Did your doctor ask about your general health?
2.  Did your doctor ask how much (or if) alcohol you drink?
3.  Did your doctor ask how much exercise you get?
...and so forth on smoking, weight change, dietary calcium, and the whole long list of things that are involved in assessing a person's health.

or for an acute disease such as an upper respiratory infection:
1.  Have you had fever?
2.  have you had muscle aches?
3. have you had nausea?
... and the things that should be asked to decide if it is likely to be the flu.

If a person is going to be graded by their patients,  then they will do what they must.  But I think the result that will come out of this is that there is often not enough time to ask the basic questions.  The beauty of this is that someone could prepare the list of questions and then test how long to allow to ask the questions, let the patient answer, and then examine the patient.  Thismight give someinisight into why doctors seemed so rushed and they miss the uncommon things.

I've done research on the time to do breast exams.  It takes a minimum of 2 minutes to do a good CBE of a supine patient, not even including palpating nodes which has an extremely low yield when cancer is present and the mammogram is negative (~1/1400).  We could allow for the time to listen to the patient's chest in at least six different locations and pause long enough to hear a few breaths.  Even paying for the few extra minutes would be cheaper than a chest x-ray.

I apologize or thinking out loud a bit, but I don't think anyone has tried to measure how long it does to do a good exam for a series of common patient encounters.  This would be a bit like the original research for the RBRVS, and for that reason a bit subject to inflated ideas of how fast one can be if they really do it right.  

Anyway, does this strike a chord with anyone?

Bill Goodson

William H. Goodson III, MD
Senior Clinical Research Scientist
California Pacific Medical Center Research Institute
2100 Webster St, #401
San Francisco, CA 94115
FAX 415.776.1977

From: Vic Nicholls [nichollsvi2 at GMAIL.COM]
Sent: Wednesday, January 22, 2014 11:42 AM
Subject: Re: [IMPROVEDX] motivations for the right dx

I have heard about the "productivity" issue. Does it help if you all
code by the level of complexity? For example, if you have 3
older/diabetes/hypertension/obesity consults and a heart/cancer patient,
I would think that would require a longer visit. How can you all be
expected to get that in without scrimping elsewhere?

Does it matter if we the patients tell the bosses thank you for spending
a few moments with us?

My thinking is that if we can help you all better, you all will help us


On 1/22/2014 11:11 AM, Karen Cosby wrote:
> I'd like to think most doctors always want to be right for many
> reasons.  First, the ability to make the right diagnosis goes to the
> heart of their professional skills.  Secondly, doctors need to be
> confident because they have to trust their skills in moments when
> their decisions can impact life and death.  I don't think most doctors
> need any more incentive than that!  However, perhaps more importantly,
> they need freedom from disincentives.  Increasingly doctors are pushed
> by limits on times, and limits of testing.  I know my productivity is
> being watched and measured, and my administration isn't shy to
> embarrass or punish me for not seeing enough patient's per hour or
> ordering too many tests.  Many groups offer bonuses based on
> productivity. However, I have never known anyone to be rewarded for a
> "good save" or "timely diagnosis" beyond their own personal
> satisfaction (which is more than enough!).

Moderator: Lorri Zipperer Lorri at, Communication co-chair, Society for Improving Diagnosis in Medicine

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