There Are No Shortcuts

“SHOW ME A BMS (Best Medical Student, a student at the Best Medical School) WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.”    The House of God

At roughly 3 o’clock yesterday I was putting together a hasty lunch in our tiny break room.  It was nothing special, just the usual—fresh mozzarella cheese and a sliced tomato sweetened with a very nice balsamic vinaigrette. More calories in than out, but what the heck—it tastes good.  As I put one forkful to mouth before scurrying back to my office to hide for five minutes, my office manager approached.  She said, “I am so sorry Dr. Fielding.  I forgot to tell you—you will have a third year medical student with you next week. She wants to go into radiation oncology.  She asked me for a list of patients that you will be seeing so that she can look up the records and get started on the history and physical notes ahead of time, to make it easier for you.”

I resisted the urge for intense sarcasm and searched for a meaningful reply.  I said, “Please tell her that she will have plenty of time with the new patients to elicit a history and to do a physical exam.  There is no need to prepare ahead of time.” My physicist was standing in the break room and looked at me questioningly.  I asked him, “Well, would YOU want your doctor to record your history and physical before even SEEING you?”  He replied, “No, but I see no reason to throw out all of the information available in the electronic medical record either.  I think it’s a way to improve efficiency.”  Spoken like a true physicist.  I am old fashioned.  I stood there slack jawed.

And then I replied, and here is what I said:  Patients forget important information.  Patients lie to physicians they have not yet learned to trust.  Patients are in denial.  Patients may detest one doctor—for the length of his hair, the sneakers on his feet, the color of his skin.  And they may open up to the next.  They may remember important details that they had forgotten, or their sister may have called from Buffalo to say that Grandma died of breast cancer, not of “bone cancer” when the cancer spread to her skeletal system.  They may admit, finally, that they are dependent on alcohol, or oxycontin, or vicodin and they may be seeking help, this time around.  And without questioning that patient, we may never know.

So here is what I really think.  The electronic medical record, or EMR as we like to call it, has unquestionably made my life easier. With templating, and Dragonspeak, the time and work it takes to dictate a history and physical and impression and recommendations has been dramatically reduced, and I am most appreciative.  But a patient is still a patient—real flesh and blood and emotions and memories that may or may not serve my purpose adequately.  We need to keep trying to get to the truth.  We need to stop propagating and repropagating the “untruths”. Without our truest and sincerest effort, all of our medicine may not provide a cure.

I told my office manager to tell the prospective student:  No need to cut and paste the history and physical ahead of time.  Dr. Fielding is “old school.”  She wants you to go in the room and see and examine the patients, and then write it up with your recommendations.  And by the way, bring your own lunch.

Really, truly, there are no short cuts.

Author’s Note: After receiving a number of comments on the original version of this post, I feel compelled to add an addendum.   What I was objecting to in this student’s approach (which I must say is “the standard” these days) was NOT her desire to read the history ahead of time.  It was her desire to actually construct most of the written history and physical in our electronic medical record before taking her own history and doing her own physical.  I do not expect a student to walk into a patient’s exam room “blind”, having never read the prior history, nor would I myself ever do so.  I hope this clears up my approach.  Miranda


  1. As a patient who was dx with NHL 13 years ago, I am GRATEFUL to an oncologist who reads (or skims is OK) my file before I come into the office. To verbally repeat my entire history each time is a waste of my time and the doctor’s. Besides, it makes me feel as if the doctor didn’t care enough to find out most of my background before I appear in the office. THEN ask me any questions you like. When I moved back to Pennsylvania I dumped the oncologist who hadn’t a clue about me even though I had personally sent a copy of the most pertinent scans, labs and treatment, plus a cover letter. Instead I travel three hours to Hopkins where they don’t have to start from scratch.

    1. Linda, OF COURSE I read the patient’s chart before I see him or her. You have missed the point entirely. What I am saying here is that a medical student should not “write” a history and physical BEFORE she sees the patient. And it IS important for each doctor to take his or her own history, because it helps us to get to know our patients. Do you really just want your doctor to walk in the exam room and write a prescription for chemotherapy? M

  2. Ding, ding, ding! That’s what makes your place SO extraordinary. We appreciate ‘old school’ as you call it. I call it personal connection, compassionate care, and good attention!

  3. I have to agree with what Linda DeLia said. I also read your post as saying that you did not want the medical student to read the histories ahead of time.

    I ABSOLUTELY want a doctor to have read, or skimmed, my history before talking with me.

    I am constantly filling in for other veterinarians and I always try to read the histories before entering the room. It gives me a base from which to work and an idea of questions to ask. But I do agree with you in that I DO a thorough history and physical of my own. I often unearth things that the previous vet missed.

    That’s what they teach us in school, isn’t it? A thorough history and physical exam is 90% of the diagnosis, if not more. Any testing should be to confirm what is suspected, not done to figure it out in the first place. There are a lot of lazy doctors out there these days.

    1. Again, sorry if I was unclear. I did not object to her reading the histories ahead of time (although she cannot, because at the satellite my patients do not come from UCSD, they come from community hospitals and therefore have no EMR until they see me). I just want her to speak to and examine the patients before constructing a “cut and paste” note for the EMR. M

  4. You are right about the merits of a new physical from “fresh eyes”. In 1982 my dad went into the hospital for a prostate procedure. The night prior the Urologist sent his Medical Student in to do a physical. After the prostate procedure (which was fine) his Urologist called all of us into the hospital room along with his Medical Student. He proceeded to announce that his Medical Student (and not him) had palpated my father’s abdomen and discovered a grapefruit sized aortic aneurysm above his kidneys that needed urgent repair. So he was wheeled off to a second surgery the following morning. The Medical Student explained that his own father had died from a ruptured aortic aneurysm when he was a small child, and that is what propelled him into Medicine. He explained that he paid a lot of attention to looking for what a lot of other doctors missed. The Urologist said that if it had not been for his findings my father would not have lived very long – it was very close to rupturing. He praised his Medical Student for being more thorough than he or anyone else who examined my father had been. My father passed away in 1995, but we always were grateful for the “bonus years” that Medical Student gave us.

  5. Bravo, Miranda, bravo!
    I say these words as someone who has not only worked in hospitals – as a registered nurse for over 40 years (egads!), but also as someone who has seen the inside of the “system” from a patient’s eyes and it isn’t always well done! I DO want a doctor who sees the human that I am and listens to that human voice (I try my best not to whine!).
    Electronic records are a help, an asset, but they are NOT a substitute for eyes, ears, hands on…and never forget, for all you non-medical people out there – those records are only as good as the person who typed them (have you ever made a typing error?) or dictated them/transcribed the dictation! Mistakes can and do happen.

  6. I understand fully what was said. I am a hospice clinical director whose job is to go through the history and find out what has happened previous. On many occasions the consulting physician reads the prior information and just regurgitates it in his consult. More than once I have had volumes of information about the patient that was all wrong due to not asking the patient the same questions but just writing what another has said.. It might seem redundant at times as a patient but it is necessaryfor a doctor to SEE-we all can read. We all can’t remember the whole picture and shoudn’t expect the doc to either. I am saddened somewhat by the use of computerized charting in the office setting. My doctor doesn’t look at me when I talk, he just types. He no longer checks my vital signs and seldom listens to my heart. I am going to solve this by getting a different doctor who will listen to me. I am not just a bunch of words on the paper: I have had shingles, sinus surgery, lost my spouse, and had a severe infection in the past year. No heart issues are on the written page. A prescription may not be needed. A real doc needs to see my eyes, my face, and then decide what I need. Soul work is important.

  7. Not meaning to imply your medical student was going to do this. I also like to review records before seeing a patient, though I would say I usually uncover more from the patient and/or their family than what is in the record if they are available.

    Our hospitalist group has a training module on documentation and we have been warned in team meetings about cutting and pasting our daily notes let alone others. I was seeing this was falling on deaf ears after continuing to see this in subsequent progress notes. Don’t know if it is a cultural thing, or a techie thing. I did notify our person who sent the initial email out to let folks the why for this as I think it is not understood. It is disheartening to see either your own stuff copied into another person’s note or to see the same thing copied day after day until the end of the stay. Not only is this unethical, it is dangerous.

    I am one of the “geekier” members of our team (and a Boomer at that!) and cutting and pasting is a useful tool in the appropriate setting. Here’s one of my fossil rants, we need to instill or have the ones following us retain the ethics around the use of technology in our lives whether it is around patient care, social media….

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