Sunday, September 18, 2011

What I Covered in a Patient's Medical History by Dr. Robin Motz

     I am continually surprised at the lack of depth and detail in many medical histories that I read that were in the charts of new patients. Of course I was trained at Columbia Presbyterian Medical Center in the late 1970's, and we were taught to allow at least a full hour for the complete history and physical of a new patient. I also have to mention that the last medical patient I admitted as an intern in June 1976 to ward 9W was a 19 year old female with new onset diabetes presenting as DKA secondary to an unknown infection. I examined her down in the ER, brought her up to the ward, and broke her DKA  20 minutes after I extracted a tampon I found on pelvic exam that  she had forgotten  she had inserted the previous month and was the source of her infection.

     We were also taught to come out and greet the patient in the waiting room and escort the patient back to our consulting room, rather than have the PA put the patient directly into the exam room.

     I would like to list here some of the questions that I find are often not asked of a patient on the initial exam by the new physician. This of course pertains to the office exam, and not to the ER exam. In the ER as I would tell my residents, the two main considerations are: (1) does this patient need a hospital admission, and (2) what disease or process can the patient have than can kill him/her before I come in to make my morning attending rounds  (and, in the case of females, ALWAYS do a pregnancy test). The following list is not exhaustive, but I believe that if the questions are not asked, the patient is not going to get the best possible medical treatment.

The order of the questions is usually unimportant, and their place on the list need not correspond to their importance.

1) Are you allergic to any prescription drugs? What was the reaction? (Important)

2) Are you allergic to any over-the-counter-drugs or vitamins or health foods?  What was the reaction?

3) Were you ever hospitalized for any allergic reaction and did you have to be intubated?

4) What prescription drugs do you take and what are their doses? What was the last one added?

5) Are you on birth control pills (many women do not think of this as a prescription)?

6) What daily vitamin and food supplements do you take?----dosage and frequency. ?Daily aspirin dose?

7) Have you ever donated blood? To the blood bank or prophylactally pre-surgery.

8) Have you ever received a blood transfusion? After an accident? or surgery? or childbirth?

9) Do you still have your gallbladder, appendix and tonsils? Any recovery problems or excessive bleeding?

10) Last TB skin test and AIDS test.

11) Last tetanus, pneumonia , and flu vaccine. .Vaccinated against hepatitis A,B; or HPV? MMR? one or two?

12) Have you ever had unprotected sex? More than once? What were the circumstances?

13) When you were a child, did an adult of either sex ever make inappropriate advances to you?

14) Any broken bones, or damages in a motor vehicle accident?

15) Any surgeries or transplants. If yes, any anesthesia reaction?

16) Date of last mammogram, pap smear, colonoscopy, chest x-ray, EKG, stress-test, bone density test.

17) Date of last eye exam. Can you read street signs at night? Are you fearful of night driving?

18) Where were you born, where did you live and go to elementary school, high school, and any college or further education. Any serious illnesses or fractures or sprains while growing up?

19) Have you ever been pregnant? How many times and how many births? Medical pregnancy problems---elevated sugar, elevated blood pressure, C-section. Current method of birth control.

20) How many siblings.

21) Illnesses that run in family. Causes of death and ages at death of parents and any first degree relatives.

22) Excessive bleeding after dental work or tooth extraction or minor surgical procedure.

23) Do you look forward to your S.O. coming home, or to coming home to your S.O.?

24) When was your last vacation?

25) Do you look forward to going to work?

26) Do you have ongoing problems with your parents or inlaws?

27) With your children?

28) If dog in the house, does dog get monthly protective  treatment against Lyme ticks? What other pets, and are they sick?

29) When was the last time you had sex with your S.O.,? Did you both enjoy it? When was the last time before that?

30) Do you have trouble falling asleep or staying asleep?

31) Have you ever consulted a psychiatrist or other mental health worker? Any prescriptions given?

32) Have you ever thought of committing suicide? If yes, have you ever actually made plans.?

33) If you have a health care proxy, who is the named person? If not your S.O., what is the difference of opinion that caused that?

34) Where do you see yourself 5 years from now? 10 years from now?

35) Is there anything you would like to tell me that I haven't covered, or ask me?

36) Have you ever traveled outside the continental U.S. If yes, did you get sick on your travels? If you traveled to a malarious area did you take the prescribed anti-malaria medicine and for how long?

37) Have you ever fainted or passed out? What tests were done if you did?

38) How many times a week do you exercise?

39) What was your weight at high school graduation? College graduation? Before first pregnancy?

40) Do you think you drink too much?

Saturday, September 17, 2011

Dr. George Thomas is pen name for Dr. Robin O. Motz

Hello All,

     Because I started this blog when I was actively practicing internal medicine, I used the pen name of Dr. George Thomas. All case reports and stories of my training and attending are true. I attended Columbia University College of Physicians and Surgeons from 1971-1975, graduating as valedictorian, and was a resident in internal medicine at Columbia-Presbyterian Medical Center from 1975-1978. Upon finishing training I was immediately offered the position of Assistant Professor of Clinical Medicine at Columbia University as well as Assistant Attending in Medicine at Columbia-Presbyterian Medical Center. I am now retired from the direct practice of medicine, and am an Emeritus Assistant Professor at Columbia University.

     My home page, which contains my CV, is at

     I am now engaged in Stress Reduction,Life Coaching, Tutoring in Math and Physics, and dealing with Relationship Problems, as well as doing volunteer work at Gilda's Club of Northern New Jersey, which exists to help those patients who have cancer as well as their families, and is staffed almost entirely by volunteers. I also write a monthly column on medicine for Inner Realm, and am the Director of the Stress Reduction Center of New Jersey, LLC.

You can reach me at:
200 Grand Ave., Suite 201
Englewood, N.J. 07631-4363
Tel: 201-569-0040
Fax 201-569-3244

Robin O. Motz, M.S., M.D., Ph.D. (Physics)

Monday, September 5, 2011

The Death of Professionalism in (Internal) Medicine

     I have been in the practice of internal medicine for 30 years, starting with my internal medicine residency for 3 years  in a big city medical school hospital and then 27 years of the solo practice of internal medicine. I was taught to go into the waiting room to greet each individual patient, escort him/her into my office to discuss the presenting problem(s), then take the patient into the exam room and have the chaperone help the patient into an exam gown. During the exam, I would ask additional questions. I would then tell the patient to get dressed and come back into my consulting room so we could discuss my diagnosis and possible treatments. During all of my training and practice I was always aware that medicine was a mixture of art and science, as well as a gestalt of the patient's medical belief system. One develops a "feel" for illnesses of various types, for the presence of stress, for histories that don't quite match the physical, for the inconsistencies in the way that the patient answers certain questions, and how to recognize when the patient resists (consciously or unconsciously) when  I steered the post-exam conversation in the direction of certain diagnoses and treatments. All of this and more is contained in the professional practice of medicine, which is a mixture of medical knowledge, science, art, psychology, and empathy.

     The concept of professionalism encompasses respect for your patients, respect for yourself, a desire for the respect of your peers, a feeling of collegiality with your fellow physicians, and, I personally believe, always placing the patient's needs first, without appearing shocked at anything the patient says. Too often we doctors forget that we define what is "normal" for the patient. (The old saying that an alcoholic is any patient who has two drinks a day more than the doctor does still holds.) You should also feel personal disappointment if you do not give the patient as much time as the patient needs (within reason), or if you ever make the same mistake twice.
You should also be able to spend the majority of your time in direct patient contact and care, rather than filling out forms, calling HMO's  and drug plans, and writing letters to Medicare. And if you find that you are getting angry during your work day or telling your personal or professional problems to your patients, you should either take a vacation or change your profession.

     When I started practice I felt proud of my practice and my professionalism. I charged more than most physicians in exchange for which I gave my patients much more  time than they did,  and all my patients were happy with this arrangement. I also treated poor people for free in my office(I allowed an hour for the initial visit, and didn't charge extra  if more time was needed), I ordered the blood tests and Xrays that  I determined that the patient needed and also made  referrals to other doctors that I thought was indicated. I also made house calls and charged my patients my usual fee for the time I spend at their house, plus $25 for making the house call,. I generally was following 8 to 10 patients at home, who I saw at intervals varying from weekly to monthly. I also had patients in 2 different nursing homes.

     Then along came Medicare, and managed care (HMO's) and drug payment plans. Suddenly I could no longer take the best possible care of my patients. Medicare began by not permitting me the $25 house call surcharge to patients, so I stopped house calls and explained why. Then I had the problem of an Oxford patient needing shoulder surgery when the best shoulder surgeon I knew was part of Cigna. Then one of my two admitting hospitals had a payment argument with Blue Cross so that my BC patients could not be admitted to that hospital. Then I had to spend time explaining to a drug plan that although Nexium was their preferred PPI to suppress stomach acid, Nexium did not work on my patient and only Prevacid did. Then Medicare asked me why I did more of a certain procedure to test for cancer than other internists did. When I wrote them back asking why more internists didn't look for cancer, I never heard from them again on that subject. The final straw was when Medicare D, which pays for drugs, decided it would only pay for generic and not brand name drugs. In some of my patients, generic Ativan, or Prozac or Wellbutrin, for instance do not work. I have now dropped all HMO's and insurance plans as well as Medicare. I still have to argue with drug plans, but that is all. It is a problem for my HMO patients, because they had to find another primary care doctor for referral to specialists, but I also got tired of telling patients that I could not recommend any surgeon in their HMO. As a final note, if I saw two Medicare patients the same day in a nursing home then Medicare paid  me less for seeing the second patient and even less for the third, so I stopped seeing nursing home patients.

     I could no longer take care of my patients in the manner in which I was trained, and so I was forced to switch to an all cash billing system. This had immediate advantages. Since I no longer submitted any bills except to the patients, I did not need an electronic billing system. And one of my staff no longer had to spend half of her workday on the telephone with drug companies and HMO's.

     But to return to the problem of the death of professionalism in medicine. The insurance companies feel that all doctors are fungible and interchangeable. Anyone would agree that the best doctor (plumber, lawyer accountant) should be allowed to charge more, but no one knows how to measure them. All admissions to hospitals have to match a computer diagnosis, so I can no longer say:"This patient looks so sick that immediate hospital admission is needed". Medicare patients whom I see still have Medicare paying for their  lab tests. I cannot say that " in my experience I think this patient needs a particular blood test",  but rather I have to invent a diagnosis to justify ordering the test. The Joint Hospital Committee invented a rule that all patients with pneumonia in the ER must get antibiotics within 4 hours of ER admission or else the hospital would be sanctioned. I got used to writing in the ER chart that the patient refused antibiotics at the 4 hour mark  after I told the patient that I was unsure of the proper antibiotic at that time. I resented the fact that I had to "game" the system to obtain what I thought was the best possible care for my patients.

     In line with the anti-professionalism trend I know of two large internal medicine practices which have installed a 900 number for after-hours and weekend telephone calls. The recorded message tells callers to either go directly to the ER, or to stay on the line where they will receive a bill for each minute they spend on the phone. This has generated some additional income and cut down a lot on after-hours  phone calls.

     I cannot help but feel that patients are not as well served if doctors cannot afford to spend a lot of time with them, even if there is not a negative result in the mortality statistics. It takes much less time to order a test when a patient has a complaint than to take the time to take a proper history, but the doctor makes more money the former way. And I detest the practice of the PA going into the exam room to obtain a history and take the blood pressure.

     There is something wrong with the practice of medicine when the most competitive residency is dermatology, since  dermatologists can charge whatever the practice will bear since neither insurance companies nor Medicare pays for cosmetic dermatology. At a typical teaching hospital, the top grossing dermatologist takes in almost twice the fees that the top cardiac surgeon does. Plus we have the old saying that one advantage of dermatology is that (barring cancer) "the patient never dies, never gets well, and never calls you in the middle of the night".