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Transitioning to a Diagnosis and Plan

by Charles Vega, MD
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    00:01 Let's talk about transitioning to a diagnosis and plan.

    00:04 And this is very important for your USMLE Clinical Skills Exam as well.

    00:11 So hopefully, you are keeping this in mind as we go through.

    00:14 Summarization, you are gonna wanna to show this on that examination.

    00:18 And that means just pulling the case together and presenting it back to the patient.

    00:23 And it does a few different things to help the encounter.

    00:26 First of all, it allows me to reflect on the problem.

    00:29 As I said, as I'm going through a patient's history, I'm considering, "Okay, this is my differential, and this is moving up, and this is moving down, now I'm adding this." So the reflection on the problem allows me to organize that list finally in my brain before I talk to the patient about what I think is going on because that's gonna be natural question as we transition from their history to my assessment.

    00:52 Second, it's a great form for quality assurance.

    00:54 How many times you have gone in the room and asked the patient, "Oh, do you have any pain?" And they say, "No." And then the attending physician comes in and the patient says, "Oh, doctor. I have this terrible headache and my leg also hurts, and I have this stomach pain as well." And you feel like, "Why didn't that happen? Why didn't you tell me about those things?" So giving the patient their story back is a way that you can check quality and make sure that there is none error that you're making or there's something they might have left out that is important to the case.

    01:24 And then lastly, it's very important for patient's satisfaction.

    01:28 So patients will now understand, I was heard.

    01:32 And therefore, they're gonna be satisfied with the clinical encounter.

    01:35 More likely to see you in the future as well.

    01:37 So just to give an example based on this very brief case of abdominal pain I've developed, my summarization might look something like this.

    01:46 "So you've had three days of pain in your upper abdomen.

    01:49 It's cramping and it's worse with food.

    01:51 You haven't tried anything to alleviate the pain, and you think that you had a fever.

    01:54 Does that sound right? Stop.

    01:58 Wait for them to--and often times, "No doctor, that's about it", or "Oh yeah, doctor, by the way, I also--I did throw up one time." And then that gives you again a more complete history that's gonna help your assessment.

    02:12 Now, how the heck do you do this in a busy practice? So I've got about 12 minutes with each patient.

    02:19 My practice is like a lot of practices.

    02:22 And I think that you have to put it in the right context.

    02:26 And using this form of interview technique gives you more information without actually adding time.

    02:32 And the reasons that I'm able to do where I just let my patients talk as much as they want is because I don't perform a general review of systems on my patients.

    02:42 It really doesn't improve outcomes.

    02:43 The general physical exam similarly, it doesn't improve outcomes, but it does increase health care cost because you find small skin lesions that now you need biopsying, extra cost.

    02:55 You hear a little extra sound in the lungs and it's tiny.

    03:00 Maybe a wheeze or maybe it's a crackle, but it's gonna involve a chest X-ray which may lead to electrocardiogram, more cost.

    03:06 That's how the general physical exam, not a targeted exam, but just generally looking head to toe on the patient could add cost, but it doesn't improve mortality or morbidity benefits.

    03:18 Just understand that the average number of issues in a standard primary care visit is seven.

    03:24 So I've got a lot to get through.

    03:25 And this is the preventive health, this is acute care, this is chronic disease care, and there's other things on the patient's agenda, like they brought in disability forms or something like that.

    03:34 So there's a lot to get through.

    03:36 But using open-ended questions as I said, gains more information than close-ended questions and very importantly, it doesn't add to the overall length of the patient visit.

    03:46 So hopefully, you have some great tools now to not only understand how important the history is but how to take a great history as well.

    03:55 And doing so will not only yield you better diagnosis for your patients', more accurate diagnosis, but I think it's gonna make both you and the patient a lot happier as well.

    04:06 Thanks.


    About the Lecture

    The lecture Transitioning to a Diagnosis and Plan by Charles Vega, MD is from the course Introduction to Family Medicine.


    Included Quiz Questions

    1. They increase the amount of information obtained from history
    2. They add to the length of the visit
    3. They make the patient feel like you are not paying attention
    4. They increase healthcare costs
    5. They misdirect diagnoses
    1. A targeted physical exam
    2. A general physical exam
    3. Closed-ended directive questions
    4. A full review of systems
    5. An alarmed timer
    1. Summarization of the patient's reported history reflected back to the patient by the physician
    2. Documenting notes while in the room with the patient during the patient encounter
    3. Filling in a full checklist of review of systems
    4. Performing a full general physical exam for all visits
    5. Using goal-directed closed ended questions

    Author of lecture Transitioning to a Diagnosis and Plan

     Charles Vega, MD

    Charles Vega, MD


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