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The Thorough Medical Data Base Makes it Easier for your Physicians to Give You Care

Be it to treat illness, prevent or minimize deterioration from disease, or to prevent disease altogether; your physician's sacred obligation to you is to capture the best scientific and medical principles and practices that are relevant, applicable, and reasonable to your individual circumstances. To the extent possible, the physician is to educate you about the many reasonable options, including often the option to do nothing. The physician should encourage your input and questions, so that a true therapeutic partnership exists. This concept of "partnership" may be truncated, of course, when you are incapacitated and a medical surrogate is not available to speak for you. Then you have little choice but to trust your physician and medical science. You must assume that your physician will follow medical and societal ethics to do what is best for you; ideally based on the best medical science and practices, previous discussions with you, an accurate data base, and, if available, your living will and/or written "medical directive". For the purposes of this discussion, the assumption will be that you, or your surrogate, is capable to communicate fully with your physician. YOUR obligation is to help your physician generate a complete and accurate "DATA BASE" about you from which your physician can make proper assessments and formulate excellent diagnostic and therapeutic strategies. There are five components to the data base: 1) The "HISTORY". This is what you tell the physician, in your own words, with the guidance and expansion from the physician's questions. Common medical experience suggests that 90 per cent of diagnostic accuracy becomes available from the subjective details of a proper history, even before the objective data that the physical examination and tests might generate. It is here that you must be totally honest with your physician. Give ALL the facts and information, even if you think some might be irrelevant. Mention ALL symptoms, all problems-- past and present. Answer all questions fully and honestly. (Remember, all interactions between you and your physician remain absolutely confidential.) Be prepared to answer questions about the following: Your previous illnesses, established diagnoses, hospitalizations, surgeries (even minor ones), procedures, names of all previous physicians with their addresses and phone numbers. Also your medication allergies/hypersensitivities. ALL your current medications and their doses. Best to bring with you to every visit the actual bottles of all your medications. Your "social" history that includes your "habits" of diet, exercise, smoking, alcohol consumption, illicit drug abuse (past or present), psychosocial/economic challenges, dental care, availability of living will and/or medical directive (that includes the medical surrogate-- the one who is to make medical decisions for you if you become incapacitated). "Family" history (health statuses/causes of death of parents, siblings, children). Vaccinations status-- i.e. when you last had (or never had) especially the following vaccines: tetanus/diphtheria/pertussis, pneumococcal pneumonia, influenza, "shingles". This is obviously a lot of "history". It may be too exhaustive to remember it all or to give it. But, it must be done, preferably within the first two visits with the physician. To help, it is perfectly good to bring with you a written list of all matters that you want to discuss. It is predictable to forget much during the stress and emotion of a medical encounter. It is also perfectly fine to bring a family member or friend with you to the visit to help you talk to your physician. On the other hand, if you think another person with you in the room might hinder your frank discussion with your physician, do not bring that person into the room. If you prefer you can request that person to join you in the room after the intial discussion and examination are finished. (You can and should, if you prefer so, request at any time the presence of a nurse or assistant in the room with you and the physician.) Other parts of the medical data base are: 2) Old records from previous physicians, hospitalization summaries, consultants notes. To the extent possible, you should already have these in your possession to give to your physician(s); but, if not, good physicians will try to get them, review them, incorporate them (or at least a summary of them) into your current record. (In my opinion, you should have reservations about physicians who do not review your previous medical records.) 3) Physical examination. This will be the subject of future articles. But, suffice it to say, I would also have reservations-- big time actually-- about physicians who would make assessments about you, order tests, medicines, consults, procedures, etc; without first their attempt to do a proper physical examination of you. Both the history AND physical examination combined have always been the cornerstone foundation of medical practice. This remains absolutely true today, even with the fabulous advances in diagnostic techniques and tests. Some physicians now minimize the importance of the history and even more so the physical examination that they consider an anachronism. This is utter nonsense. Again, more on this topic later. 3) "Test Results": blood tests, radiologic studies, procedure reports. 4) Assessments and Plans: What your physicians think and advise. These should be the subject of continuous reassessments and revisions, as nothing about the human condition, including illness, remains static. (I would also have reservations about physicians who rotely repeat the same assessments and plans, time after time.) 5) Living Will and Medical Directive. Every responsible person should have these, regardless of age or health status. (Well worth it to consult a lawyer to have these done properly. Your personal physician can also advise you about the contents these should have.) Now, here is the key suggestion: The best way to assure accuracy and thoroughness is to have with you, at all times, a written copy of your own medical history-- your own copy of your medical data base. Initially, you can compose this yourself. It does not have to be perfect, just complete-- all inclusive. (There are now web-based programs that can help you do this. These are known as "personal medical records", or PMR's. Nice, but not absolutely necessary.) The best and easiest method is simply to ask your personal physician, past or present, especially one who has been thorough, to gives you copies of the most recent comprehensive visit notes. These notes should contain all of the "history" information discussed above, plus all recent physical examinations findings, laboratory studies, medications list, allergies, consultants notes, procedures, hospital discharge summaries, and list of diagnoses. Ask your physician(s) for periodic updates. Or, better yet, ask for copies of all notes, test results, reports, etc, as they are generated. A good physician should be eager to give these to you. (The physician may ask you to sign a "release", although, in my opinion, this is unnecessary.) There are NO reasons-- repeat NONE!!-- why you should not have in your possession a copy of your comprehensive medical record, your medical data base. Or, at least a cogent summary of the important medical facts. In other words, YOU, yourself, should carry with you at all times your own medical data base, ready to share it with all your personal physicians, physician consultants, emergency room physicians, dentists, podiatrists, etc. Have hard copies. Have them also in secure internet web-based formats if you like. Give them to your medical surrogate(s) too. Lots to think about. I am confident, however, that your commitment to help your physician generate the best possible medical data base about you, along with your concurrent effort to have it with you at all times, will improve your medical care many fold. (EG)

(This piece appeared several years ago on the senior citizens resource website

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