Physician Responsibility and Accountability: Importance of the Diagnosis and Plan.

Our patients come to see us because of concerns and complaints regarding their health and physical well-being. They spend their emotional energy, their time, and their resources (monetary and other) in order for us to provide care. In general, they ask only that we do our best and that we involve them in the decision process. They ask us to listen to them, to perform an examination, to make a diagnosis, and to formulate a plan. They do not seek our approval, our condescension, our arrogance, or our pity. They ask for a diagnosis and involvement in the plan. The diagnosis is a crucial component of the entire process. It is important that the diagnosis be specific and suitable for the implementation of a comprehensive treatment and/or care plan. For example, it is difficult to provide definitive recommendations or a comprehensive treatment management program for “wrist pain,” which is a symptom. In contradistinction, “scapholunate dissociation with sprain/avulsion fracture of the dorsal wrist capsule: left” is a defined condition from which a comprehensive plan may be formulated. An important portion of our obligation to patients is to create a thoughtful and comprehensive plan. The true value of the planning process is often lost in the hubbub of a busy office session. However, the plan is an essential and vital component of the visit, often has a profound impact on the patient’s life, and may improve the efficacy and efficiency of follow-up visits. The plan should include the following: (a) prognosis; (b) additional diagnostic testing planned; (c) activities and limitations including work restrictions; (d) the next possible steps including surgery, if that is indicated; (e) the need for or absence of the need for consultation; ( f ) medications prescribed or prescribed and discontinued; (g) therapy; (h) orthotics or prosthetics; and (i) the return visit with a summation of what is planned and expected to occur on that visit. The coordination and timing of the follow-up visit is often overlooked or rushed. It is imperative to avoid visits for the physician’s convenience. A 5-minute follow-up may cost a patient a day of work or require a day of child care. It is also important to specify why that visit is important (e.g., check the wound; make sure the cast is fitting and comfortable; determine that “the pain is appropriate”) and to detail the events of that visit (e.g., dressing change, X-rays). One mandate of meaningful use includes an “after-visit summary,” which many treating physicians felt was superfluous. However, in critically looking at the current electronic medical record, the concept of the after-visit summary, if it truly includes a plan, guides the care process, improves the patient’s understanding of his or her injury or disease, may clarify misunderstandings, and may provide very real value. Perhaps this perceived inconvenience may turn out to be one of the real values of electronic care.