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Recently a young woman came to my office. She hadn’t seen a doctor in several years and requested a checkup. The bulk of the annual physical isn’t the physical at all — it’s the talking, and we discussed diet, exercise, sleep, mood, alcohol, drugs, smoking, sunscreen, vaccinations, contraception, safe sex. In the last few minutes, however, I did turn to the physical exam.
I proceeded the way I do all my physical exams: I start with the eyes, ears and mouth and methodically work my way south — checking the lymph nodes and thyroid of the neck, listening to the heart and the lungs, percussing the abdomen, all the way down to feeling the pulses near the big toe.
Except that there’s one gaping divide in that north-south trajectory. Like most internists, when I get to the navel I skip down to the knees.
There is something faintly preposterous about doing a “complete physical” and then proceeding to hopscotch past a few key organ systems – especially for those of us in the primary care fields, who pride ourselves in taking care of the “whole patient.” We refer our female patients to the gynecologist for their regular preventive care, while our male patients might get sent to the urologist. It’s like our patients are Humpty Dumpty, and the pieces are divvied out between different medical fields.
When I started out in my medical practice, I vowed not to be the kind of doctor whose physical exam ends at the navel. Why should my patients have to see two separate doctors to get a complete exam? In my first years of practice, I did pelvic and breast exams for all of my female patients as part of their regular medical care. In the days before electronic medical records, I kept one of those heavy green laboratory notebooks in my desk to note of all the Pap tests I had done so that I could follow up with the patients when the results became available.
My patients were thrilled with this arrangement. Although I always offered a referral to gynecology, not a single one chose it. To a one, they preferred that their care be completed in one visit instead of two. I felt good too — I was offering comprehensive primary care for my patients and not overloading my swamped gynecology colleagues with these routine exams.
But while the pelvic exam doesn’t take that long, it does take time, and equipment, and a chaperone. My practice grew busier and it became harder to fit in all the moving parts. Unlike the gynecology clinic that was set up for these exams and the record-keeping, the medical clinic was not, so I was always scrambling on my own.
And after a few years, I simply could no longer manage it all. I regretfully retired my green lab book and speculums, and began referring my patients to gynecology, just like all the other internists. I was disappointed and so were my patients. We’d taken a step backward in comprehensive care.
Over the years, my guilt has been assuaged somewhat by guidelines that now recommend less frequent Pap tests and pelvic exams. Many of my patients for whom I performed an “annual Pap” no longer needed it, though I still feel a pang of guilt about shirking these parts of the body.
The young woman I was seeing that day was actually due for a Pap test — it had been more than three years since her last one. But with three more patients already checked in and waiting to be seen, I simply didn’t have the time.
I’d just read a recent study in the Annals of Family Medicine showing that comprehensive medical care is associated with lower costs and fewer hospitalizations. The study had some limitations, but it reinforced what most doctors and patients intuitively understand: fragmented care is worse for everyone and costs much more. I felt terrible that I was about to contribute to the fragmenting of care for this patient.
But our system is set up to favor fragmentation. It’s so much easier to write a referral to a gynecologist than to do a pelvic exam myself. It’s far quicker to refer to a rheumatologist than to figure out which complex tests to order, and then have to follow up on the results and figure out what they mean. It’s much simpler to refer to a neurologist than to take the time to figure out if a patient’s dizziness is serious or not.
In our current environment, being “comprehensive” just means more work for the primary care doctor. No one is allotting more time for this work or reimbursing for these extra efforts, so it’s no wonder that most patients leave their doctors’ offices with a fistful of referrals.
Regretfully I handed my patient a referral to gynecology, and I apologized for not being able to do the exam in my office. But she was entirely sanguine about it. She was used to going to separate places to care for her different organ systems, so this didn’t strike her as odd at all.
To me, that was perhaps the saddest part of all, that our patients are so accustomed to fragmented care that they no longer think of it as a problem. Fragmented care has become the norm.
There are efforts under way to change the way we deliver care, particularly with the concept of the patient-centered medical home. The goal of a medical home is that all of a patient’s medical services would be located in a single place with a coordinated team. Rather than have the patient run from one place to another, the care would come to the patient, and there are financial incentives to keep care centralized and comprehensive.
But we’re trying to build these medical homes on top of a deeply rooted and deeply fragmented infrastructure, so progress right now is measured in baby steps. We’re a long way off from putting Humpty Dumpty back together again, but I’m staying hopeful.
Danielle Ofri’s newest book is What Doctors Feel: How Emotions Affect the Practice of Medicine. She is a physician at Bellevue Hospital and an associate professor of medicine at N.Y.U. School of Medicine, as well as editor in chief of the Bellevue Literary Review. She spoke on Deconstructing Perfection at TEDMED.