Thirty years ago, the promise of the electronic health record was beginning to open up vistas of power in medical treatment.
The Problem List
The simple “problem list” originates logically in a physician’s scrutiny of a patient’s maladies. Organ systems which are not functioning properly, as evinced by the appearance of symptoms and signs, need medical attention. Frequently, the application of appreciation and remedy takes more than a single episode of effort. The patient usually is revisited at intervals, and re-examined. This re-visitation is essential in all but the most trivial and easily remediable problems.
The simple annotation of whether a condition has improved or worsened is key to understanding the value of any remedies attempted. In ignorance, many imagine or reply remedies, with no expectation of re-visitation and evaluation of their efficacy. This ignorance, unfortunately, is widely becoming a general impression of medicine. A patient has high blood pressure, and a pill is given. Problem solved! But not really.
The actual pharmacopoeia utilized is irrelevant to skillful medical practice. Blood pressure is to become controlled within certain parameters; that is the only goal. How it happens is nearly immaterial to that goal. Several interventions may be offered, such as dietary, exercise or medications. The only judgment to be made is whether the goal is actually attained.
Problem lists work well when an acute, immediate, discretely definable and simple problem arises, such as a broken leg. The patient’s “medical history” is a compilation of all various problems. A broken leg arises to the forefront of concerns; later, as it heals, if becomes relatively inactive on the list. The nature of the problem list is deceptively simple.
Medical Taxonomy and the Problem List
Handling the problem list requires expertise in medical taxonomy, that is, a definition of the problem to the appropriate level of precision. This is where the profession of medicine and the habits of bureaucracy diverge. As bureaucracy has taken the upper hand, the taxonomy becomes distorted and unusable.
For example, I saw a patient today who began complaining of eye pain in late October. The goal of diagnosis – the naming of disease – is rather similar to the creation of the massive, polysyllabic German words that collate all sorts of elements to express one idea.
To start, the patient had eye pain. Immediately, the challenge was to eliminate intraocular pathology, which is an urgent problem. Tonometry was normal; a slit lamp examination was performed and showed no defects. The diagnosis shifted to eye pain without intraocular pathology. Such a problem becomes much less urgent, and forgiving of patience.
Pain is a manifestation of Neurology, and needs a neurological approach. Pathology in neurology involves finding “where” before “why.” In this patient’s case, there were no evident problems from receptor to cranial exit. The sensory nerves of the eye generally come from V1 and exit through the superior orbital foramen, carrying general somatic afferents to the upper face, skull, and eye; in the company of other nerves including CN III, IV and VI. The patient had no pathology of extraocular movement, or pupillary diameter. There was no vision impairment. Extraocular examination showed no entropion or lash infolding. Patient constantly fiddled and searched for a foreign body throughout the examination. there was no evident conjunctival laceratorion of policy. The conjunctival sac had been lavaged numerous times over several months; there was no need to look for pathology there. There was no history of welding, grinding or being around projectiles.
The pain was sharp but not excruciating, and triggered by occipital pain. It had a unilateral distribution, and retro-orbital general focus. Laboratories showed no leukocytosis. The sedimentation was 2. Head CT was unremarkable.
At this point, it’s safe to call the pain a V1 neuralgia without evident pathology. That elicits several ideas – cluster-variant migraine, or forme fruste of a viral neuritis such as zoster, but in a very small and clinically occult manner.
The above is a laying-out of ideas, signs & symptoms, and the taxonomic development of a problem description. A problem must be described in terms no more vague or exact that the evidence merits. Problems are kinetic – their names change with every visit, every diagnostic procedure and intervention.
Why ICD-9 sucks.
ICD-9, now obsolete, sucks because it is designed and utilized to push diagnosis towards overly-precise definition beyond that which evidence demonstrates. It drives me wild. Uninformed or poorly-educated clinicians throw around the terms CHF, COPD, BPH carelessly. (Congestive heart failure, chronic obstructive pulmonary disease, benign prostatic hypertrophy.) Disturbingly, these diagnoses are wrong. I would rather see the term “dropsy” used than CHF unless a person knows what they are talking about. Without some sense of pathophysiology of the heart, “dropsy” is a fine term.
Similarly, “dyspnea” is not COPD, and “BPH” often masks prostate cancer.
Why ICD-10 sucks worse.
ICD-10 is a death code. It is HORRIBLE in describing non-lethal processes. Don’t patronize – I’m coding in the damn structure as we speak. It sucks in describing pain, and dermatology. And everything else.
Sometimes a patient has a 1.5 cm dusty, stuck-on appearing papule, with pigmentation extending from its base outward from the papule on the normal skin. That’s a typical-looking SK with concerning changes in the surrounding normal skin. That’s a good SK to biopsy.
ICD-10 doesn’t even allow me to code for “papule.” As a medium of verbal communication, it records my observations as a “skin thingy.” Same for, “damn, it looks like a melanoma to me!” which is something you might want to put on a consult.
More crap about the Problem List.
The Wise decided that after I spend a minute or two figuring out this guy’s eye, he needs a prostate examination, a Kennedy-Hawkins test, checking between the toes and using a monofilament on his tootsies. That’s called MEDICALLY-MANDATED ADD. Your attention span to one area of the body is limited to the attention span of a goldfish (9 seconds, they say.)
“Your eyes are fine, but you have epididymal varicosities, sir.” About the only time you can give a conscious patient a really good testicular exam is when his eye is killing him, I suppose.
Great ideas gone bad.
So I no longer have a language in which to speak of the pathology of the patient. The language has been stripped of any of its finesse. The pretense that IT could serve the medical chart – for instance, by stripping and indexing the word “eye” out of years of medical records – now insists that I express the patient’s problem in cave-man style.
The other 37 items on the overgrown ICD-10 problem list suggest that I spend time telling him about safe sex, vaccinations, handgun safety in the home, the risk factors and manifestations of major depression, and all sorts of things that would have been called “negligent inattentiveness,” but has now been decreed as a “comprehensive examination.”
“Isn’t it still true, sir, that your Grandmother died of cardiac disease?” “Was your language-of-origin still English, sir?” “Have you contemplated gender reselection?”
The patient selects the scope of the visit. We should respect that selection. All the quality horseshit about patient-centered care is stirred up to disguise that the medical visit is drifting into utter triviality.