Another small instance of the difference between medical and surgical approaches to hospital life: the history and physical, familiarly known as the H&P. This is supposed to be a complete summary of the patient’s current problems, past medical/surgical/social history, medications and allergies, physical exam, and available laboratory data. To the internist, especially the residents, this is a work of some detail, which can occupy a few hours, and comes to several pages when written out fairly.
To surgeons, on the other hand, it’s a task to be finished as quickly as possible on the way to somewhere else. The rules quite reasonably require that one must be written and on the chart before the patient goes into surgery, as there are many things which will need to be known while the patient is still unconscious or unable to answer coherently. Thus, I have written an H&P in five minutes while waiting for anesthesia to get an iv into a vascular patient with a tourniquet on a bleeding limb before we go back to the OR. On the trauma service, one fills in the checkboxes on a form in between resuscitating the patient, entering orders, and paying close attention to the CT scan in progress (usually a good deal more attention is given to the CT than to the form). Even under routine circumstances, I’ve worked it down to an artform: I have my own mental template, which I scratch out on the paper and fill in known points while flipping through any paperwork that came with the patient, then scribble in the rest while talking to the patient, and fill in the physical exam bit while talking to my attending on the phone. 15 minutes, 20 if complicated. (In fact, this is one of my most standardized private methods of assessing the interns, in addition to how omniscent they are on rounds: how fast can they write an H&P? I’m a little despondent about the ones who still, at the end of the year, spend 15 minutes talking to the patient, then another 10 minutes writing things out, and only then are they ready to do orders or move on to another job.)
(Speed should not be at the expense of thoroughness or completeness. I’ve also worked out a few key questions to elicit the information that patients tend to forget, or consider not worth mentioning: a medication list is key, since it will show up all the major medical conditions (so many people feel that if their blood pressure is treated, they don’t have to list it as a problem; or elderly people may not know that they’ve been diagnosed with heart failure, but the combination of lasix and a beta blocker will suggest the possibility); are there any other surgeries you’ve had; do you have diabetes?; anything else you’ve been treated for? etc. On the plus side, if you need an H&P really fast, the history of present illness is usually pretty quick and obvious, eg patient fell and cut arm on glass 3 hours ago and has had tourniquet on ever since then, complains of numbness and paralysis in arm. Plan, will go to OR right now.)b
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