When I work shifts at immediate care centers, as I am going through my questions and answers to template an idea about who my patient is. In medicine we follow this concept that Lawrence Weed developed in the late 60's called POMR. (modern version is called the SOAP note) It's a way of organizing data collection while speaking with patients so a clear understanding can be made of the problem. He created it due to the complexity of medical conditions in patients. In 1969 he wrote:
"...accept the obligations of meeting many problems simultaneously and yet to give to each the single-minded attention that is fundamental to developing and mobilizing his or her enthusiasm and skill, for these two virtues do not arise except where an organized concentration upon a particular subject is possible."
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| -an old SOAP note (note _OAP to left margin) |
So the doctors of today are not dealing with anything new when it comes to tackling the "laundry list" of issues that patients arrive to the doctor with. Many of my contemporaries claim current society is so overexposed to processed food, biased television/internet news, unhealthy work hours, lack of exercise, alcohol/drug consumption and now over utilized prescriptions that the health care of today that the modern day patient is different than yesteryear. Guess what....no matter what kind of plate you put the meal on - its still a meal. I will always teach my medical students, the importance of establishing rapport first. Get the trust of the patient and you will figure out the answer in the ailment. The problem I see with going to the doctors office today is that there is a concept of hurry (no doubt started with medical insurance industry "streamlining" billing) to limit a visit to a diagnosis. So no longer are we treating Joe Schmoe, we are now taking care of a high blood pressure reading or an elevated sugar or a month of feeling depressed. Doctors are being encouraged by an industry to label a visit with one bullet diagnosis. Savvy doctors will list down several diagnosis to attain maximum reimbursement for services rendered but the problem I see is docs concentrate on claiming "I found diabetes in you with your blood test" or "your X-ray says arthritis" so much so that we tend to make an la carte treatment plan based on a list of 3-5 diagnoses and hope the treatment "takes" when the patient come back in a few weeks.....100% better. So.... if I send a Porsche with strut problems to a Chevy volt mechanic and he tries to fix what is basically a suspension issue-it will probably not perform like it did before. On the same analogy if an automobile just has a loose nut...most mechanics can tighten the nut and stop the rattling. But......human nature is to wait until the lose nut has caused a cataclysmic suspension failure resulting in cashing in your 401K to fix the problem. There is nothing like the experience of being given a long list of things that have to be fixed when you thought it was just a loose nut. I guess it's the same way with an annual wellness screen, you go in healthy, you come out with an inventory of what is abnormal and "has to be fixed."
As medical insurance steps in the make the visit to doctor and hospital an affordable event, they need an algorithmic way to translate SOAP diagnosis into something they can reimburse (and not just trust the doctor is billing properly for expertise rendered during a visit) Here comes ICD coding. As a patient you leave the doctors office with 3-5 ICD codes. This is what it has come to, you are now an accumulation of codes. Even as I call my specialists to let them know of my patient I am sending, the conversation usually starts as: "...I have a 76 year old Alzheimer's patient with depression and subdural bleeding on Aricept and Lexapro coming to see you for non control of symptoms." The answer will usually be: "...add Namenda over the next month and I will see him in the office for further adjustments then". I hope and pray that during the 30minute visit with the specialist, my consultant will see more than a few ICD codes in the exam room, and try to give expert advise on better options for treatment. The back room event that occurs is the specialist with a booked up schedule will rely on my ICD codes in building up opinion, possibly do some "fancy" testing to refute or support the codes and stream line additional treatments. Doc will then have the patient come back after another month or two (booked up schedules!) or come back and see me. So goes the typical "spin" of going to the doctor/hospital.
If you look at why ICD was created...it was to record causes of death in Europe. Like a registry. Since the 1700's it has changed from International Lists of Causes of Death to the current WHO adaptation of International Classification of Diseases-10th revision. The original lists were compiled as population studies for figuring out why kids were dying early and scientifically devise an intervention for this large group. Great application....and it probably was key in curing many childhood diseases. My bias is that when you use population information and apply it to the individual....it doesn't guarantee success. In a broad sense you may prolong life for the species but only at the sacrifice of ignoring suffering from the individual. The Ecological Fallacy points out that the outcome of the individual is not determined by the outcome of the group (my truncated version). In medicine when someone breaks through the usual statistics of a certain disease; specialists call it an "atypical reaction"/lawyers call it a missed diagnosis/laymen would call it a miracle. What ever it is called, its the demonstration of the human cell/energy to attempt repair and survival. I believe if you provide the soil for DNA to "do its thing" it will continue forever. Science says cell replication ends at about 70-80 years of life. Living an unhealthy lifestyle (bad soil) will bring death sooner (Standard American Diet). Living a healthy life will push back death (The Blue Zones of Sardinia, Okinawa, Nikoys and Ikaria where people are leading productive lives into their 100th year of life).
So how do we become a centenarian? I don't mean an American Centenarian-(nursing home, bed bound, depressed, diabetic, demented, cancer-ed, bypassed, dialyzed, catheterized, emaciated)....I mean a centenarian from one of those previously mentioned places in the the world. No question we have to live with a diagnosis and try to neutralize each ICD-10 code with the best protocol treatment plan possible. My calling is to think with an Integrative Medicine mind. I would attempt to "reverse" what ever brings you into the doctors office. The problem is knowing when to go. If you are listening properly to the cues your life is giving you, it will be easier to recognize abnormal change. This requires knowing what is normal. This requires education. There are so many ways to empower with knowledge; books, seminars, hospital lectures, DVDs, Cd's, internet. From former to latter you have to be weary about reliability of the information. Once you recognize the cues, then see the propelyr trained healer, you should be able to revert your "flare up" to "status quo". The same knowledge that helps get out of temporary illness should be used to determine if your lifestyle is going to sustain you. My patients have a choice to change their disease manifestation for the best chance at arriving to their 90th birthday. By living with disease, it doesn't mean taking the prescribed medicine for the ICD-10 code and going about your business. It means always looking ahead to that "miracle", always trying to provide your DNA with fertile soil, it means adjusting the loose nut before your suspension crashes. It usually means seeking out the advise of someone who can vacillate between using the awesome power of modern medicine and the awesome potential of ancient wisdom. Don't ever just settle for being a disease controlled on medicine because the likelihood is......another disease/code is coming-listen for the cues.
