A chief complaint

In the email that I got from the person at our billing department it was explained to me that I couldn’t bill the patient for a follow up visit if he/she has no complaints. She further elucidated that when they have no complaints, I should write the diagnosis as a chief complaint. I follow patients with chronic kidney disease and many of them come to me to monitor their kidney function, blood pressure and to manage risk factors for progression of their disease. Many of them do not complain of anything specific until very late in the course of their disease.

In Medical school and Residency, we learned that a “History and Physical” has a seven essential elements: chief complaint, history of present illness, past medical history, social and family history, physical examination, review of laboratory and imaging findings, and an assessment and plan. The chief complaint, we were told, is better described using the same words used by the patient. A follow up note, on the other hand, has four elements: subjective, objective, assessment and plan. I do not recall ever being told to include the patient diagnosis in the chief complaint so that I can bill him. In fact, we never received any education about billing patients!

Yesterday, I received a copy of one of my colleagues note. It started with the chief complaint: “I am here for a postoperative global assessment!” While, I was pretty sure that the patient did not say that, I knew exactly what it meant. It is the only way my colleague can get paid for his services. This is our modern day Medicine. Physicians have to document their “services” in a way that appease bureaucrats in insurance companies and Medicare and not conform to their trainings.

Instead of compassionate care and sound clinical judgment, we are now witnessing the gradual transformation of Medicine into lines of services that are gradually falling into the abyss of hardhearted automation. This automation has to comply with regulations, paperwork requirements and guidelines. All while maintaining a great score on the patient satisfaction surveys to sustain the physician salary without performance cuts.

The state of current Medicine has a chief complaint and it is not about how to bill better. Medicine is sick .The history of its present illness is that physicians have left the field to others to tell them what to do and how to do it best. At this time, it appears to be a hopeless case. Its prognosis is poor! I guess the chief complaint and the diagnosis are the same: Medicine has a terminal illness.