All Things Medical

Future

PART 1

THE PREVENTION OF MEDICAL ERRORS

Es Irrt Der Mensch, So Lang Er Strebt

(As long as human beings strive, they will make errors)

Johann Wolfgang von Goethe

(1749-1832)

Introduction

A medical error has occurred anytime a healthcare provider plans a medical action and it does not succeed as intended, or the wrong plan is used. These errors can include problems in medical practice, failure to diagnose, procedural problems, system failures, or product deficiencies.

Ninety-eight thousand people per year die from medical errors, a number that represents more deaths than occur from automobile accidents or breast cancer. This statistic, published by the Institute of Medicine in 1999, has prompted efforts by the Joint Commission on Accreditation of Healthcare Organizations to focus the accreditation process on operational systems critical to the safety and quality of patient care.

What is the Institute of Medicine? Who are its members? Are they a governmental organization? What is the funding source?

The federal government created the National Academy of Sciences to serve as an advisor on scientific matters. However, the Academy and its associated organization (e.g. the Institute of Medicine) is a private, non-governmental organization that does not receive direct federal appropriations for their work. The Institute of Medicine’s charter establishes it as an independent body. They use unpaid volunteer experts who author their reports, each of which undergoes a rigorous and formal peer review process that must be evidence-based where possible, or noted as an expert opinion where not possible. Many meetings of the Institute of Medicine are open to the public, or the committee may deliberate amongst themselves until they reach consensus. Any potential conflict of interest could disqualify a committee member.

One cannot dispute this committee’s findings—the best minds are at work. In addition, the Joint Commission considered it serious as well, for they have launched a nationwide effort to minimize medical errors in healthcare organizations.

Let us define what medical errors are. The Joint Commission has categorized a long list of hospital errors that have resulted in death or injury, the so-called sentinel events. This is necessary so that the Joint Commission can investigate and make sure that hospitals have put systems in place to prevent the error from reoccurring. These sentinel events are:

• Anesthesia related: death or injury may result from anesthesia.

• Delay in treatment: failure to diagnose in time, treatment delays resulting in disability or death and wrong diagnoses are all medical errors. An incomplete medical examination is often the reason.

• Elopement: serious injury or death could result when patients leaves facilities of their own accord before diagnosis.

• Infection-related: lapses in sterile technique may result in an infection.

• Maternal deaths: obstetrical deliveries may result in injury or death.

• Medical equipment: medical equipment failures may result in disability or death.

• Medication error: physician, pharmacist, or patient error may result in injury or death due to improper or wrong medication use.

• Operative/post-operative: complications may result from surgical or post surgical care.

• Patient abduction: infant abduction from newborn nurseries have occurred.

• Patient falls: the failure to identify the fall-risk patient, and/or the failure to safeguard the patient may have serious consequences.

• Perinatal deaths/injury:injuries or death may occur around the time of birth.

• Potassium Chloride: the accidental direct intravenous injection of potassium chloride can result in cardiac arrest.

• Restraint deaths: restraints are a last resort to protect patients from themselves and staff from patients. Restraint use is only for the shortest time necessary and includes frequent monitoring. Failure to monitor these patients may result in medical complications or death.

• Suicide: guidelines must be in place to identify and monitor the suicidal patient.

• Transfusion: an improper matching of a blood transfusion can cause injury or death.

• Ventilator: mechanical ventilation is often necessary to breathe for patients who are unable to breathe for themselves. Improper ventilator settings, machine failure and incomplete monitoring may result in death.

• Wrong site surgery: wrong-site surgery can result from failure to identify the precise surgical site.

• Wrong test performed: improper orders or failure of interpretation of orders will result in the wrong test.

Medical errors do not only happen within hospitals. They can occur in any healthcare facility including outpatient surgery centers, clinics, doctors’ offices, nursing homes, pharmacies and patient’s homes. In fact, home care fires are another sentinel event claiming victims over age sixty-five in most instances. Risk factors identified are:

1) Living alone

2) Absence of a working smoke detector

3) Flammable clothing

4) Home oxygen

5) Cognitive impairment

6) Smoking has been a factor in all cases reported

An incomplete medical history and physical examination will result in failure to diagnose. The same is true of an incomplete screening laboratory analysis and risk factor analysis. This is a crucial part of any physician-patient interaction from the diagnostic standpoint, and there is nothing more important for creating rapport and a lasting, trusted relationship between the physician and the patient.

When a medical error has occurred there has been a breakdown of one or more of the built-in safety measures put in place to prevent such mishaps. These safety measures are the responsibility of the entire healthcare team. Physicians must get involved by making certain that patients are educated and made to take responsibility for their care. Patients must understand that they are not a passive member of the team. They are the most important member. They must feel free to ask questions and satisfy themselves that the medical diagnostic and treatment option they choose is the best one taken for an optimal result.

There are basic steps any patient must take when confronted with a new diagnosis that has long-term future impact. These are:

• Learn all that is possible about the problem or problems.

• Speak with the physician;

• Get information from the internet or books;

• Look to support groups for assistance.

Only then will patients be in a position to decide upon a treatment plan. Physicians want their patients to do this. Careful evaluation of all the risks and benefits will produce a satisfied patient who will adhere to a well-planned proper course of action.

Medical errors are:

• Medication prescribing and use

• Medication use during care transitions

• Patient identification

• Performance of correct procedure at correct body site

• Communication during patient handovers

• Control of concentrated electrolyte solutions

• Catheter and tubing connections

• Infection control

• Diagnostic errors or failure to diagnose

Patients can and must assist in prevention. This book will provide clinical examples that illustrate the error discussed.

Medication prescribing and use

When a physician writes a prescription, it must be legible. If it is not, the pharmacist may have difficulty. If a patient cannot read the prescription, rewriting it is mandatory, or, at least, spelled out in writing. Sound-alike medications with similar spelling have been confused, so patients must be alert less they receive the wrong medication. There are also look-alikes, and generic medications made by different manufacturers may have a dissimilar appearance. Therefore, the moral of the story is—if there is an issue about any medication, clarify it before taking the medicine.

The busy pharmacist could misread the medication or confuse it with a medicine with a similar sounding name. The use of pharmacy technicians is common. Failure of the pharmacist to check everything the technician does has also caused prescription errors. This complicated process must be double-checked.

When a physician sees a patient, the patient should bring a list of all medications prescribed by all physicians. Some larger clinics and University Medical Centers will have a full medication list printed out for patient evaluation and confirmation. If not, then patients must come prepared either with a full medication list including vitamins, herbs and dietary supplements, or with a brown-bag with the medications. Physicians will appreciate this help and realize they are dealing with an educated and informed patient. Patients must be wary of physicians who do not think this way.

Example: A patient suffered from sleep apnea that she could not control with the recommended C-pap therapy. This is a breathing assist mechanism to prevent obstructive breathing. A dental appliance, another form of therapy, also did not help. The patient did much of her own research, and was more aware of all the physiological mechanisms of sleep apnea then most physicians. Out of desperation, she saw another doctor in consultation. And when the patient told this doctor about all the research she had done to understand her illness, the doctor stopped her and asked, You do research on sleep apnea? The astounded patient said, I want to know about my problem. That’s the doctor’s job. he said, That’s not for patients to do." Her inclination was to get up, say thank you, and leave, but she did not. She asked me what I thought. I told her, at that point, you would have lost all confidence in that doctor, and I would not have blamed you if you did just as your inclination suggested, thank him, left, and found another doctor.

Patients must be certain that every physician they see in consultation is aware of any medication allergies. This is the only way to avoid receiving a medication that may cause harm. No physician can know what any patient may or may not be allergic to. Prescribing medication is a gamble, and will remain so until the era of personalized medicine: medication prescribing based upon genetic profile. At this time, a doctor does not know what any medication’s effects will be on any individual patient.

Case in point:

A patient had open-heart surgery. His doctors prescribed numerous medications. Prior to surgery, his blood count was normal, and after surgery his blood count decreased. The blood loss during surgery should have resolved and gone back to normal within weeks of the surgery, but it did not; in fact, it continued dropping to lower levels. His doctor sent him to a hematologist who, thinking of all kinds of rare diseases, recommended that he have a bone marrow biopsy. The patient decided to hold off on this procedure while he did his own personal research. He went on the internet and studied his medications, all of whom had the rare potential of causing anemia. Could this be it, he thought? Is one of the medications causing this? After understanding the possible risks of delay and getting approval from his doctor, he stopped the last one prescribed that was for prostate symptoms and repeated his blood count after about a month. Lo and behold, it was back to the pre-surgical and normal fifteen grams. He had had a rare side effect of a medication prescribed for his enlarged prostate. This information now occupies a prominent place on his medical chart. He saved himself a bone marrow biopsy, and his hematologist learned something too.

If patients are allergic to any medication, it is wise to wear a wristband identifying the offending agent.

Patients must know the following when given a prescription:

• What is the medicine and what does it do?

• How long must it be taken and at what intervals?

• What are the side effects to watch out for? If they occur what must be done?

• Are there any potential drug-food interactions that may cause a problem by enhancing or hindering the action of the medicine?

• Are there any activities to avoid while on the medication?

Pharmacists must provide information about each medicine they dispense. The patient must read this information and have questions answered before the medication is taken.

With liquid medication, a marked syringe is more accurate than a kitchen teaspoon or tablespoon.

A hospitalized patient who receives an unfamiliar appearing medication must not take it without clarifying the issue first. This is critical in the era of generics when the same generic made by different pharmaceutical companies have a dissimilar appearance.

When hospitalized and receiving intravenous medication, the nurse knows how long the intravenous is supposed to drip before it runs out. Patients should be told as well and if not they should ask and inform the nurse if the run-out timetable is behind schedule.

If hospitalized, a nurse must check the patient’s identification wristband before dispensing medication. The failure to do this can not only lead to medication errors, but also testing errors, transfusion errors, and the discharge of infants to the wrong family.

Medication use during care transitions

Patients are often transferred from unit to unit within the hospital: regular room to intensive care; intensive care to regular room; acute care hospital to the rehabilitation unit; emergency department to intensive care or regular room; and so on. Medication errors occur during these transition points. This is a common occurrence and the cause of many medical errors.

Case in point:

A woman was walking her dog down a residential side street and noticed a neighbor lying unconscious on her garage floor. She rushed in, was unable to revive her, and called the paramedics who transported her to the closest hospital emergency department. Examination revealed a seventy-five year old unconscious woman with a bruised head. An emergency CT scan of the brain revealed a collection of blood under the lining of the brain known as a subdural hematoma. This hematoma was very small, so her physicians elected watchful waiting rather than surgery. The patient regained consciousness, but was very restless and agitated, a state that persisted over the next few days. She also had some difficulty in walking, lost strength in one of her extremities and required the use of a walker. She was rational, but stated she Was jumping out of my skin. This persisted until her physician prescribed a tranquilizer in an attempt to calm her. The anxiety improved, but the patient then became confused and disoriented. This worried her physicians who ordered further tests thinking that perhaps the hematoma had enlarged or other cerebral pathology had developed, or there were undiagnosed medical problems. There were no new findings identified. Thinking that perhaps the confusion and disorientation was due to the tranquilizer prescribed to calm his patient, the physician discontinued it. Indeed, within two days the patient’s problem had resolved. All this time the rehabilitation transfer was not possible because this requires a clear mind and a cooperative patient, neither of which was possible while she was having her symptoms. Different physicians and a new healthcare team attended to her in the rehabilitation unit. They started her on rehabilitation, but after a day or two they found her to be confused and disoriented making progress impossible. They called her hospital physician to tell him what had happened. In the meantime, she was in the rehab unit for a full week and could not make any progress due to her altered mental state. When her physician arrived, he discovered why the patient had relapsed. Somehow—and no one could tell him how—the medication that he had discontinued because it caused her confusion and disorientation had been restarted. He never found out why. This medical error caused considerable delay, set back the patient’s progress and could have resulted in serious consequences.

Patient identification

Misidentification in a hospital can cause the following:

• Wrong blood could be administered that could harm or kill

• A wrong test could be performed

• A wrong procedure could be performed

• A test could be performed that was meant for another patient

• Wrong treatment or intravenous fluids or medication meant for another patient may be dispensed

Therefore, patients must never object to wearing a wrist identification bracelet. There have been considerable identification errors, so safety measures are now in place. First, it has been determined that using two identifiers improves reliability. The possibility that there can be more than one patient in the hospital with the same name is the reason for the double identification process. The two identifiers come from the following list:

• Name

• An identification number

• Telephone number

• Address

• Photograph

• Social security number

• Other patient-specific identifiers

An example: in a surgical suite, the operating room staff should ask all conscious patients their name, date of birth or another identifier and check this information against the wristband, consent form and other documents. Only then should the surgical site be marked.

Barcode technology is another patient identifier. The wristband, patient specimens, medications and blood all have the same barcode and they must match with every therapeutic or diagnostic procedure performed.

Patients must be certain that they undergo proper identification when approached by hospital or clinic personnel.

Wrong site procedures include wrong person, wrong site, wrong organ, and wrong implant. This error is preventable, but does occur. Eighty-eight cases occurred in 2005. Preventive protocols are in place:

• During the pre-procedure stage, verbal questioning, by wristband and by consent form must identify patients. The procedure, site, and any prosthesis or implant must also be identified

• Whoever performs the procedure must mark the preoperative site while the patient is awake and aware

• The entire operating room staff will take a time out: a time period where no clinical activity is taking place and all staff can concentrate on identification verification, positioning, procedure site and any prosthesis or implant that is to be used

Performance of correct procedure at correct body site

A patient must sign a consent form when undergoing surgery or an invasive test of any type. The patient reads the consent form. Patients are entitled to understand the nature of the procedure, the benefits that are supposed to accrue, other possible alternatives to the procedure and the risks of the procedure.

The surgical site is marked as described; wrong site or side surgery is a tragedy that cannot be undone.

Communication failures during patient handovers

A number of health-care practitioners and specialists in many settings including emergency rooms, acute care hospitals, outpatient clinics, intensive care, and rehabilitation units treat patients. Patients will meet different professionals on three different shifts. Medical information must remain unchanged when leaving one unit to transfer to another unit. It is unfortunate that at this critical transfer time, breakdowns in the transfer of information do occur and may lead to serious consequences. This is the time for the patient to be alert—assuming one can.

This is another one of the main causes of medical errors. Here is an illustrative example:

A forty-nine year old woman had a sudden episode of unconsciousness manifested by a seizure. Paramedics transported her to the closest hospital emergency department. A CT scan of the brain revealed a right frontal cerebral bleed. The cause of the bleeding could not be determined from the scan. The medicated patient was unresponsive, restless and agitated, and regained consciousness within ten hours. There was no apparent neurological residual, and on subsequent clinical and MRI follow up over a year, the blood resolved leaving no trace of the underlying pathology. She was on anti-seizure medication for a time, and remained symptom free for one and a half years. Then she had another similar but much shorter episode, regaining consciousness within a half-hour. Extensive brain studies demonstrated normal cerebral arteries and ruled out arteriovenous malformation, cerebral aneurysm, arteriovenous fistula, dural sinus fistula, brain tumor and other diagnostic possibilities. This left some rarer diagnostic possibilities.

I was not the patient’s doctor, but, at the patient’s request, I spoke with the neuroradiologist who had interpreted her MRI films taken during hospitalization. Since the usual MRI did not reveal the source of the bleeding, he recommended an MRI of a type that I had not heard about. He thought that an MRI with and without infusion, T2 star gradient with echo might be able to pick up the lesion where the regular, routine MRI’s could not. I had him repeat the exact test, and I wrote it down and he confirmed that what I wrote was accurate. The neuroradiologist assured me that this special test was the best chance of diagnosing what he now suspected after ruling out so many other possibilities.

I then gave a copy of the test to the patient who by this time was being discharged and learned to her dismay that the excellent neurologist assigned to her case when she was admitted was not a participating doctor for her HMO, nor was the hospital she was admitted to as an emergency a part of the HMO network. She had to start over. I told the patient to take charge of and direct her own healthcare. She was now responsible for acquiring a new medical team, and these physicians had to learn about her and take over all future care; and the quicker the better because of a probable delay in the transfer of her records to any new doctor. The HMO directed that she go to another hospital for the test further disturbing the continuity of her care. She was in the middle of a fabricated healthcare maze prone to miscalculations and misadventures because her course had changed and many human beings were involved. As we embark on the new and massive changes in healthcare to come, the situation may worsen. That is why all patients or their advocates must be in charge.

But I’ll just have the new doctor order that test you wrote out for me. Why should I worry? she asked.

You should worry, I said, because the neuroradiologist gave me the information about this test, that in all my experience I had never heard about, which I now pass on to you, and you will pass it on to the new doctor, and he will tell his secretary, who will call the hospital and speak to another secretary, who will then speak with a radiological technologist to put you on the schedule for the recommended and unusual test, which by now has passed through multiple hands. In addition, by the time the order has passed through this maze, God knows what it will look like when you appear for the test. Trust me—these foul-ups do occur.

She took my advice and in attempting to confirm that the new hospital could perform the test, she learned that it could not. What they had done already was place her on the schedule to do the usual MRI. Unfortunately, the usual MRI did not identify the cause of her bleeding. She phoned the HMO to tell them that they had approved the test at a hospital that could not perform it and the hospital had scheduled the wrong test anyhow. This resulted in multiple and lengthy phone hassles until she assured them that she was attempting to prevent them from making a medical error. They advised her of another hospital where the proper test could be performed.

The patient, now the wiser in the ways of potential medical error production, went so far as to call the technologist at the second hospital that would be doing the test. Reading from the paper I gave her, she said, This is the precise test that the doctor ordered, Yes, we will do that, answered the technologist, J. I will be performing it myself, he said.

I told her to be sure when she went for the test, even though she had spoken to the person who would perform the test, that she confirm that the exact test that had been ordered was to be done. She assured me that it was now foolproof, because she had personally spoken with J. who would perform the test. I repeated what I told her.

Well you guessed it—when she arrived for the test and filled out forms stating the test ordered, J. was not there, but another technologist had replaced him. The patient was wise enough to understand this woman was not J., so she asked her where J. was. Oh, he couldn’t be here today, she answered. What test are you going to perform? the patient asked. The woman technologist answered, Just a regular MRI.

The patient controlled herself and said, No that’s not correct. Here is the exact test that was ordered, and she handed her the instructions.

Oh, said the technician, that’s a test we don’t do very often, but if that’s what you want we can do it if we get a doctor’s order for it. It’s not what I want, the patient responded, It’s what the doctor ordered and what J. said he would do. They did the test after taking more time to confirm the doctor’s order

Had this patient not taken charge of her own health, a medical error would have occurred; a test already done that could not identify the cause of her bleeding would have been repeated; twenty-two hundred dollars would have been wasted, and a serious diagnosis would have been delayed—and that delay had the potential for great harm. You can also see the wasteful financial impact that might have occurred. Is there any wonder that our medical care system could break the bank?

The truth of the matter is—medical errors occur because systems break down. Some of these errors lead to delays, a waste of money, injury—and some lead to death. The healthcare system with its conflicting insurance rules, approved hospitals, unapproved hospitals, approved doctors, doctors not on the list, approved and unapproved testing facilities, different reimbursement formulas, and necessity for approvals from non-medical personnel, is cumbersome and complicated and the patient is in the middle and that is why patients must direct their care. Patient safety, life, limb and financial well-being are all at stake. With the healthcare changes to come what will happen to this already overburdened system?

Because this patient took charge of her health, she had an exact diagnosis established: venous angioma, an untreatable condition as it serves as part of the cerebral venous drainage. She also had an adjacent cavernous malformation of the right frontal lobe that arose from the venous angioma. The patient sought neurosurgical consultation to determine the therapeutic options—surgery, gamma knife radiosurgery, or watchful waiting and anti-seizure medication. In the meantime, she has immersed herself in Google to learn all she can, since most primary care physicians have had little or no experience with these rare cerebral blood vessel malformations. After much research and consultations with several neurologists and neurosurgeons, she has taken the conservative medical and non-invasive route. She is doing well—armed with a final well-researched decision. She took charge of her health—and the decision she made, by personal education and consultations with several experts, is a well-researched decision that she is now comfortable living with. This is an optimal solution, better for the patient psychologically and comfortable for the attending physicians.

Control of concentrated electrolyte solutions

Potassium chloride (KCL) is the culprit here. In the first two years of keeping such records, ten patients died by the direct intravenous administration of the concentrated solution of potassium chloride. The nurse or pharmacist adds small amounts of this concentrated solution to a liter of IV fluid to make a very dilute KCL solution used to treat low potassium levels. However, if given undiluted, the medical error is irreversible—death is the outcome. For this reason, KCL is banned from hospital nursing units. It is designated a controlled substance like narcotics, and can only be kept in the pharmacy under many safeguards including limiting who may handle it. Each vile is required to carry a label stating HIGH RISK and MUST BE DILUTED.

Catheter and tubing connections

Very ill patients may require multiple catheters and tubes used for drainage of body fluids and as portals of entry to deliver necessary medications. Misconnection errors, resulting in wrong medication delivery to the wrong body site, have occurred. Nine such cases reported resulted in eight deaths and one loss of function. The Joint Commission has recommended preventive measures that all hospitals must adopt. They include:

• Labeling of all high risk catheters such as those that enter the spinal canal or an artery

• Staff must always trace a tube or catheter from its point of origin to the patient before connection is made with a new device or an infusion

• When a patient arrives at a new setting, staff must always recheck and trace all patient tubes and catheters from their source

• Staff must route tubes and catheters having different purposes in different directions

• Non-clinical staff, patients and families must get help from clinical staff whenever there is a perceived need to connect or disconnect infusions or devices

• High-risk catheters must be labeled and not have injection ports

Infection control

There are estimated 1.7 million infections in United States hospitals per year resulting in 99,000 deaths. These infections are urinary tract (32%), surgical site infections (22%), pneumonia (15%), and bloodstream (14%). There have been twenty-eight different organisms acquired in hospitals.

Hospital acquired infections, also known as nosocomial infections, occur in five percent of all hospitalized patients. There are many reasons for this scary statistic:

• Many hospitalized patients have weakened immune systems making them more susceptible to infections.

• They may have a weakened immune system because they have an illness causing this increased susceptibility, or they are receiving treatment that weakens their immune system. The end-result is decreased resistance to bacterial, viral, or fungal infections.

• Medical procedures can introduce infectious agents into a patient.

• Patients admitted with infectious diseases may transfer the infection to other patients.

• Hospital workers and visitors are also susceptible to infections acquired from patients.

• The same principles apply to all healthcare organizations including nursing homes, clinics, dental and other healthcare offices, child care centers, homes, restaurants, and schools.

Healthcare workers can carry antibiotic resistant bacteria, viruses and fungi on their hands. Proper hand hygiene will reduce the incidence near 100 percent. Washing with soap and water can be effective if done well, but it is time consuming, done with every patient interaction and can result in significant dryness and irritation to the hands. Therefore, hospitals have introduced an alcohol rub hand washing system that can kill bacteria in fifteen seconds, can reduce bacteria count 10,000 fold and is gentle on the hands. If hospital personnel do not wash their hands before examination, the patient must insist they do. All physicians should place a sign in their examining rooms—Don’t be afraid to ask if I’ve washed my hands.

The overuse of antibiotics has resulted in bacterial resistance to common antibiotics. This may result in failure of treatment for an infectious disease. A more rational use of antibiotics based upon treatment guidelines followed by physicians and accepted by patients will reverse this trend.

Diagnostic errors and failure to diagnose

Failure to diagnose is a common problem. Forty percent of malpractice cases fall under this heading. The fault lies with patients, doctors and even insurance companies:

Patients are at fault when they never see a doctor, ignore mild symptoms, and refuse diagnostic studies.

Doctors are at fault when they do not make the time necessary to take a thorough medical history and perform a complete medical examination. They are so busy with follow up care and acute care medicine that the initial thorough review can get short-circuited. Patients can play a vital role in prevention here. If it is felt that an initial examination has been incomplete, never be afraid to ask. Oversee the complete examination process.

Insurance companies may cause delays in diagnostic testing.

These are but a few of the problems that can lead to failure to diagnose.

The Joint Commission has recommended patient safety standards for all healthcare organizations. They undergo a yearly review and every organization will adopt these standards. Safety standards are in place for the following healthcare organizations:

Ambulatory care and office-based Surgery

Assisted living

Behavioral healthcare

Critical care hospital

Disease-specific Care

Hospital

Home care

Laboratory

Long-term care

Networks

The Joint Commission publishes these standards on their web site: JCAHO.org.

PART 2

THE COMPLETE MEDICAL EXAMINATION

All things are to be examined and called into question. There are no limits set to thought.

Edith Hamilton

1867-1963

Introduction

A complete medical examination includes a:

Medical history

Physical examination

Basic laboratory data

Risk factor analysis

Patients who have a good grasp of their personal medical data can prevent becoming a medical error statistic.

This book is for patients who want to take charge of their health and for members of the health professions interested in a review of the basics.

The book will speak to the patient and attempt to answer the questions asked over the years as the health care provider (physician, nurse, physician assistant) gathers a medical history and performs the physical examination. Patients need to know why the examiner asks specific questions, what benefits accrue from a thorough medical history, complete physical examination and, risk factor analysis, how the data is put together to arrive at the correct diagnose; and how this information will enable the prevention of medical errors.

The point needs repeating: involving the patient is the latest emphasis in the ongoing battle to prevent the medical errors that affect patients and healthcare workers alike. Being an educated patient is the best defense. When patients have a good grasp of their health problems, they become an important member of the team whose goal is to provide optimal and safe care.

Granted, this may all take time and presumes an ambulatory patient with the time to spend evaluating options. However, the time needed may not be available if the patient is involved in an acute life and death medical or surgical situation and is in an unfamiliar medical environment. In this instance, a written, or otherwise instantly retrievable summary of the medical history may be life saving. This is one reason why there is such a national impetus to promote electronic medical records, but until this day arrives, healthcare professionals must provide their patients with this important data in writing and not assume that when patients are told medical facts they will remembered for all time. Patients may soon forget what they learned in their doctor’s office.

In the absence of this critical, instantly retrievable medical information, and if a patient is unable to provide good clinical information, physicians, who are seeing a patient for the first time, will not be well-prepared for the very difficult and responsible position of having to provide care.

The book will discuss the important first step to take in health evaluation: a complete medical examination. Those educated to perform this vital examination include all physicians; but many super specialists, concentrating on their small slice of the body get rusty. Therefore, the responsibility falls to primary care physicians defined as internal medicine, pediatrics and family practice, and also a nurse and physician assistant.

The author will use the word physician when writing about the professional who captures a medical history and performs a physical examination. More often than not, the word physician will mean a doctor of medicine, either an M.D. or D.O., and, also in this case, a nurse and physician assistant.

Physicians first learn how to evaluate a patient in their early years of medical school. By the time budding physicians have graduated, they have had experience in taking medical histories and examining patients under close senior physician supervision. At this point, medical students have learned how to learn, and only a continuing experience will allow them to polish their craft. Nurses can receive master’s degree specialized education in the performance of the complete medical examination, and physician assistants can be educated to perform this function as well.

In the 1920’s the Metropolitan Life Insurance Company demonstrated that policyholders who underwent annual complete medical examinations lived longer than those who did not. On the strength of these statistics, the American Medical Association recommended periodic examinations of all healthy persons starting at age thirty-five. The general patient population has not yet received the benefit of this recommendation. Corporate executives have utilized the concept often, but the average person has failed to get a complete medical examination in any great numbers. What is the reason for this?

The most important physician-patient interaction occurs at the initial visit when patients present for a complete medical evaluation. This is time consuming and expensive. It stands to reason that a well taken medical history and full head-to-toe physical examination has a better chance of uncovering medical problems than an examination done in a hurried and cursory manner. However, the complaint I continue to hear from patients is that The doctor had one foot in the door and one foot out. As already mentioned, the average physician is very busy with acute and follow-up care, so they schedule their time to take care of the many patients seeking help. Therefore, the complete medical evaluation has suffered—and we are paying the price in unhappy patients, overworked physicians, medical errors and a malpractice crisis.

There are those who argue against the periodic complete medical examination, saying that it may not be cost effective in terms of the yield. They propose that the evaluation of patients who have no symptoms should be selective and based upon the age and sex of the patient. Major medical organizations in the United States and Canada have endorsed this approach. Most physicians do not dispute the wisdom of these endorsements, but cling to the belief that the complete medical examination is important, even though they bemoan the time constraints that make it difficult, and they cite the following reasons:

(1) Patients expect a complete medical examination.

(2) Physicians have had numerous experiences where the performance of the complete medical examination has elicited unexpected critical findings.

(3) A well-done complete medical examination enhances the physician-patient relationship. This must be emphasized; anything that yields a close relationship between patient and physician will promote understanding, rapport, and minimize medical errors.

(4) The complete medical examination offers the best opportunity to learn whether there are health risk factors that must be rectified and monitored. A full understanding of these risks will allow one to take charge of their health and play an important part in the prevention of medical errors.

(5) The complete medical examination provides medico-legal protection for patients and physicians. The structured complete medical examination can reduce lawsuits filed for this reason because there will be a greater likelihood of making the correct diagnosis.

Is there anything wrong with the complete medical examination? The major difficulty is its cost. It takes the physicians’ time and costs money, in most instances more than patients can afford and more than insurance is willing to pay. Because if its cost, the complete medical examination has fallen by the wayside for the average patient. Hence, the cornerstone of early detection and prevention, the complete medical examination and risk factor analysis, is often incomplete. In a medical office where the physician is so busy with acute and follow up care, here is where the well-educated nurse and physician assistant can be of great help.

As part of the complete medical examination, there are a large number of initial screening tests ordered. Invasive testing puts the patient at some risk. Therefore, the benefit to risk ratio test must be acceptable before performing these tests.

The complete medical examination does include some risk factor questions, however there is not enough information provided to allow correlation of the risk factor with the disease. Patients can take their own risk factor analysis (see The Slim Book of Health Pearls: Am I at Risk?) This book allows patients to take their own risk factor analysis, which then can be shared with their physician.

The best a physician can tell anyone after successful completion of the full examination is that, The examination is normal in all its aspects. There is a certain amount of reassurance in that statement, but inherent within it is that there is no guarantee. It is impossible to predict what the future holds, but following preventive and treatment recommendations will minimize the risks for death or disability. Patients understand this and are appreciative of the assurance that can come from a complete medical examination—if one can get a thorough one. This book will tell what it entails.

So, let us now go through a medical history and a complete physical examination just as an average physician does with medical students and patients in their private offices and in the hospital. The book will give clinical examples after each section. These examples, illustrating the history or physical examination point discussed, are from my own and colleagues experiences. There will also be some examples of unusual cases of great clinical and human interest.

Patients need to have a better understanding of:

The art and science of history