Vitals, Schmitals, Who Needs’em? by Sylvia Mustonen DO

vital-signs

You would think that something as simple and basic and obtaining a patient’s vitals would be the easiest part of a visit, regardless of the location, this is something all patients have done to them. But how many of them actually get their vitals taken correctly?

Coventry health care, which was acquired by Aetna in 2015 provides Medicare Advantage plan coverage to millions of older Americans.   In order to earn their money from Medicare, Coventry has to jump through a few hoops. One is to make sure they gather basic “health “ information on their covered population.   They do not use this for treatment, they do not use this for research, they do not use this for population data management, they do not share it with anyone, not even my personal physician. Their only requirement is to tell Medicare that all of their “people “were checked.

First they sent me a letter telling me of this wonderful free service. When I failed to respond, they started calling me to get me to sign up for a visit. I gave in.

So Coventry/Aetna hired a huge crew of nurse practitioners to go to homes and obtain a history and do a physical and report it back to Coventry/Aetna HQ.   Should we call them Caetna or Aetventry?

The NP came to my house and spent 45 minutes with me. She was a pleasant young lady, who had previously worked as a nurse in orthopedics and then changed track to go to NP school. She was employed by Coventry to make house visits on people like me. She had no idea that I was a physician.   She never asked and I never volunteered the information. I wanted to just be a patient and she how she performed.

She had a tablet to record her information. She went through the questions as fast as she could, not looking for any result that would send her to another screen requiring further data gathering. Then she took my blood pressure.

She did not roll up my sleeve .

She did not place the scope any where near the antebrachial fossa. She just touched it to the upper inner portion of my upper arm. She did not press hard enough to hear all 4 Korotkoff sounds. I wonder if she knew what those sounds were or who Korotkoff was or even cared.

She weighed me on her scale. It was 10 pounds off from my scale.

She quickly briefly shined her light into my mouth and ears and eyes, through my glasses, and had me say ahh. She looked at my ankles. She smiled and finished recording her findings.

In my humble opinion, she did it all wrong. The history was incomplete and therefore useless. The exam was done wrong and therefore erroneous. But she checked all the boxes on her iPad and told me that I could have the information emailed to me in about 3 weeks.

The next day I saw my personal physician, an internist and a major Midwestern clinic which has medical school, research and world class reputation. I had a sinus infection and needed medication.

The young person who escorted me to the exam room had the most lugubrious expression on her otherwise un -emotional face. We were behind a patient in a wheelchair who needed help to get on the scale. She, who never gave her name to me and whose name was only on her name badge, made an executive decision not to weigh me or obtain anything other than a temperature.   I think it would have required waiting for the wheelchair bound patient to move through first and she did not want to put that much time into vitals.

By the way, the area where weight, height, and temp are obtained is right in the open area in front of the check out desk, where all patients, coming in and going out, are triaged. Privacy? – over-rated. HIPAA – who needs it?

In the exam room, she sat at the computer and began to read my list of medications. Of the 10, nine of which are vitamins and supplements, there were three she could not pronounce.   I suspect she could not define the purpose of most of them. She certainly had no interest in getting it right.

She then explained that she marked “ weight declined” on her list of check off boxes because she did not weigh me herself. How is it that I DECLINED a weight when she actually decided not to bother obtaining one? She said she could not accept the weight done yesterday by the Coventry health care NP and just wanted me to know what she had to say on the computer. It is now her story verses my story if it ever comes up for question.

Both she and my doctor had the word “caregiver” on their name badges. He had been demoted from physician, doctor and even provider. She demoted from nurse and medical assistant to the blandness of a caregiver. The man pushing the patient in the wheelchair is a caregiver. These two have a title, training and should be recognized for that. But the administration has mixed all people with health care education into a bland emotionally vapid pudding and call all of them “caregiver”. I bet the CEO has a title prominently displayed and you will definitely know who he is if you ever see him.

So, to summarize:

  • The EMR, in essence, made my clinic care giver a liar.
  • The EMR used by the NP is full of in accuracies.
  • HIPAA was violated a lot.
  • No health information was shared between the two systems just the same as no animals were harmed in the making of any movie.

I paid for all of this with my Medicare premium money and my copay. Was there quality involved? If you ask me then I would say no, but if you ask the iPad or the EMR, the answer is hell yes, because the right boxes were checked.

How many other patients are going through these same motions earnestly believing that someone is recording something important, accurately and that quality care is being given by people who give a SH&T? The sad truth of the matter is that it is not important to those who read it nor is it accurately obtained by those who are recording it.

I think it is vitally important for physicians to shuck this off and go back to the direct care model.

 

 

 

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  10 comments for “Vitals, Schmitals, Who Needs’em? by Sylvia Mustonen DO

  1. Fred LaVenuta MD
    February 24, 2016 at 2:01 pm

    Lesson: Orthopedists don’t take BPs (unless the patient is bleeding out). BTW, I had the same experience when I went for my draft physical in the mid-60s. The “doc” had one earpiece of his stethoscope in his ear and the other one hanging out while talking to the “doc” next door and ausculting my chest.

  2. Avery
    February 24, 2016 at 1:19 pm

    Having been hospitalized more than 15 times in my 70+ years and subjected to the usual number of office visits for someone of my age, I’ve had more indifferent vital sign readings than I’d like to think. But modern medicine isn’t notably worse at doing it right than it’s ever been, in my experience. Some nurses and aides and doctors were and are meticulous; others were and are filling in blanks.

    Not to nitpick (well, I guess I am), isn’t the BP cuff secured above the antecubital fossa, not antebrachial fossa? Or are the terms interchangeable? I’m not a physician or a nurse, just a medical writer/editor.

    • Doug Farrago
      February 26, 2016 at 6:39 am

      I think the antecubital fossa is the answer. I am a doctor and had to actually look this up because, well, that is not what I do every day.

      As far as being meticulous, I agree that there is normal variability but with the new industrialized model of medicine it has only gotten worse. You will never see “time with patient” as a quality metric

  3. John Parkin M.D.
    February 22, 2016 at 6:15 pm

    If something is not worth doing it certainly is not worth doing well.

  4. Dave Mittman, PA, DFAAPA
    February 22, 2016 at 4:46 pm

    Interesting.
    I recently went to a physician, and for the first time in my professional life I did not tell him/her I was a PA. I can tell you the history I was asked for a very specific problem would have been asked better by a PA student. The exam was passable. The explanation of what I had, and what we would do about it-again, left way too much to be desired. Seriously. I was worried and there was little to any communication.
    I can tell you every exam I did was directed to and at the problem. And it was damn good.
    So where do we all go from here?
    BTW, I did not say anything. First time in my life for that also.
    Dave

  5. Sir Hakum of Hugo
    February 22, 2016 at 11:04 am

    Data for the sake of data.
    Feed it all into IBM’s Watson (aka HAL-9000)
    Population medicine.
    Treat the herd.
    Thin the herd.
    Your provider is a company, a facility, and governmental agency

    12 years and I’m outta here.

  6. drhockey
    February 22, 2016 at 10:42 am

    This has been going on considerably longer than you think.
    Back in medieval times, when I was an intern, I had to report for a military draft physical. The group of us men (about 12?) were nude in a circle, and together facing forward or backward depending on the portion of the physical. When the doctor with the (cold) stethescope came by for the pulmonary exam, he listened only once on each side of the upper back. To me, it was apparent he only checked for moving air. So, being a self-described clever non-conformist, I decided to close my glottis when he came to me. Well, he came to me he did not even break stride as he went on to the next person.
    Talk about “dry-labbing” it!

  7. Perry
    February 22, 2016 at 9:38 am

    Quality has nothing to do with the patient getting good medical care. Quality is defined by what is marked on the boxes and what the patient reports in her satisfaction survey.

  8. RSW
    February 22, 2016 at 8:51 am

    Surely they checked your fifth vital sign?

  9. Steve O'
    February 22, 2016 at 8:07 am

    Well, they say in business school, you manage only what you measure. But all that medical measurement once served a purpose – to provide accurate and meaningful information to a trained human mind. Since the human mind has been discarded, the information is both mandatory and unneeded. Therefore, any number recorded is as useless as any other number. One might as well record estimated eyeball diameter (each side.) It is openly conceded that “vital signs” are simply trivia to be recorded.
    If the patient’s brain is dead, the state of health of the other organs matters only for potential transplantation. Signals arise in the body, go to a dead organ, from which nothing returns. But in modern healthcare, we press on regardless of this single organ failure.
    American healthcare seems to have been struck by a profound anoxic brain injury. And we stumble onward, doing meaningless things regardless. Is there any surprise that our horror motif involves zombies? Put a white coat on them, and you have a “caregiver.”
    Mediocrity is promised, but rarely even that is achieved. The blame is always the same. Turn a job into blindingly painful assembly-line work, and ‘caregivers’ – who maybe at one time were as motivated as you and I – grow to hate their job and hate their patients. They behave like harried and unskilled zoo employees at a failing roadside zoo. Victims hating victims, the money goes up and elsewhere, to distant executives in nicely tailored suits, making decisions that they half-understand. The parts of healthcare that they do understand, indicate that they are behaving in a negligent and reckless manner. But they are not the ones who have to confront the actual victims – they hire pawns to do that.
    What part of this sounds like an honorable new future?

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