Apparently my post yesterday hit an important nerve.  First my point about subspecialists should not be generalized to all subspecialists or the idea of subspecialists.  As opposed to the 1970s when I trained, too often I see subspecialists now only considering their organ when evaluating a patient.  Too often I see both generalist physicians and subspecialists failing to fall back on the basic principles of a careful history and physical and then understand what specific tests to order.

One can blame academe somewhat.  Too many subspecialty consults in academic centers end with a laundry list of tests, excluding almost anything that could ever be part of the differential diagnosis.

One can blame the payment system.  The generalist physician, rather than spending adequate time with the patient, orders a consult to save time.

One can blame the patients.  Tara Parker-Pope initiated these expenses even though she should have known better.

That’s where my daughter’s ankle comes in. At the time, the injury seemed unremarkable. Her pediatrician suggested waiting it out, but after a month with no improvement, I sought a second opinion from a sports medicine specialist, who ordered an M.R.I., but ended up referring her to a pediatric orthopedic surgeon.

Patients (and physicians) too often forget that time is our friend. We become impatient when the physician cannot explain the symptom(s) immediately, so we abandon our generalist and figure that the subspecialist is a better choice.

We in academe must teach our students about the thought process in medicine.  We in academe must role model history taking at the bedside, and then have discussions about that.  We must demonstrated physical exam clues and explain how we use them in our decision making.

We must take the time to do things right.  We have a responsibility to all the patients our learners will see in their careers.

We must remember that tests do not replace a careful history, they supplement that history.  We must teach parsimony, a rare consideration during training.

And we must tell all those who will listen that good medical care takes time.  We must stop talking about productivity.  We are not making widgets, we are caring for important people – our patients.  Each patient deserves our full attention and adequate time.

Only then can we produce high value cost conscious care, for it starts at the bedside, not at the computer order screen.