However, in the last 15 to 20 years I have noted a serious and progressive decline in the ability of the average emergency physician to perform a competent history and physical exam. In this day of the EHR, many patients have physical exams recorded that never took place. I recall (I’m semi-retired now) medical students and residents arriving for their emergency department rotations without even a stethoscope. I can’t speak as to whether these same deficiencies apply to other specialties, though I suspect they do. We need to take a closer look at how medical students are being taught and instill in all new physicians and physicians-in-the-making that there is more to medicine than ordering a bunch of tests and then trying to explain away, or in some unfortunate cases, simply ignore the unexpected, for no other reason than it doesn’t fit our preconceived notion of diagnosis and/or disposition.

—Jerry W. Jones, MD, FACEP, FAAEM
Houston, Texas

I believe your comments are right on point with what we as a specialty need to be more outspoken of. The video that IOM created for laypeople (https://m.youtube.com/watch?v=fStBWT6fa3E) is a mockery to physician insight and perception that we would only favor one diagnosis and do not communicate with our patients throughout their hospitalization. The woman with left upper extremity pain that was apparently anginal in nature states that her long-term morbidity is associated to the delay in her diagnosis. However, they fail to mention if she may have reported any other symptoms to the emergency physician evaluating her on that given day that may have led him/her to believe that this could be acid reflux. Further, did her symptoms evolve over those two weeks and manifest into more obvious anginal symptoms? If we admitted every chest pain that would be considered clinically low risk, what are the long-term implications to our health care system? If we admitted every patient that stated they have a “high pain tolerance” and know that something is wrong, what do we further due to our growing narcotic epidemic? Yet, we find more ways to burden our specialty in reflecting on delays in diagnosis and pointing fingers for the growing narcotic epidemic.

We have all recently been asked to meet the CMS standards for severe sepsis in all of our patients. However, what about the patients in our respective institution that ultimately do not have sepsis? It may appear they could have an infection, but for fear of not meeting regulatory standards, still received the 30 ML per kilo bolus and broad-spectrum antibiotics. Maybe the patient even had a lactic acidosis and an interstitial infiltrate that could reflect pneumonia. What are the implications and long-term morbidity and mortality associated with these patients, that we now have been asked to ensure we hit all quality metrics within a three-hour window (just click the sepsis bundle and everything will be taken care of—but the patient)? Did we not learn from the pneumonia initiative, requiring initiatives such as these have negative implications? However, when a patient is negatively impacted because a physician attempted to use his critical decision-making and determine appropriate line of action, he immediately will be referred back to the CMS standards and the IOM initiative and be asked why.