Month: April 2017

It’s time to get rid of the “Review of Systems (ROS)”

When it comes to the “review of systems,” I’ve been a natural, a savant, a prodigy you might say.

During my 1st few weeks of medical school, I remember doing  mock interviews with fake patients, long before I learned anything about “HPI,” or “ROS”,  physical exams, billing or anything medically relevant for that matter. As other students stuttered, trying to figure out what to ask a lady pretending to be schizophrenic, I calmly sat in front of her, going head to toe, asking a variety of questions, just to pass the time and to not appear incompetent.

Does your head hurt? 

Does your eye hurt? 

Does your heart hurt? 

Does your belly hurt?

Does your leg hurt?

Does your skin hurt? 

And so on it went for 3 or more minutes, after which my neophyte colleagues and teaching assistant marveled at my ability to methodically pepper her with so many questions with no guidance what so ever. I was born for this; the ability to comfortably take a good detailed history and putting it all together to diagnose and treat anything that might come my way.

As a primary care internist, my ability to take a good history continues to serve me well everyday. But I loathe the “Review of Systems”; that multi-system checklist of endless questions, taught as a necessary skill for every physician, but in reality is just a force fed requisite of every patient visit, created by the billing god Hades himself and fellow deities at the Center for Medicare and Medicaid services.

Knee pain? I will ask you about seasonal allergies. Level 3 billing. Meh.

Hypertension? I will ask you about rashes. Level 4 billing. OK.

Chest pain? I will ask you about your memory. Level 5 billing. Hades is pleased!

In all seriousness, a skilled physician can and should ask about all the relevant systems necessary to make a proper diagnostic and treatment plan. But the reality is, many of us mindlessly go through this ritual on too many visits, without any purpose except to meet documentation and billing requirements. And in the current state of medicine, where visits are condensed to a few minutes, (many of which are occupied by the EMR) spending even 60 seconds going through the ROS check list is a misuse of time and energy. It’s mindless work and that’s frankly insulting to the skilled physician who sincerely thinks about each patient and carefully chooses what to inquire more about.

It’s time to get rid of the Review of Systems, as a 1st step in a major overhaul of what’s required of us for billing.


How parenting has helped me cope with the struggles of modern medicine.

A free moment to read my favorite healthcare blog is difficult to find. The days are packed with complex time intensive patients. In between patients, I struggle to complete documentation and take care of a myriad of tasks, making phone calls and plodding through cumbersome electronic medical records. Then, there’s still  actual paper work to review and complete. I still have to make time to occasionally read clinical literature in addition to interestin blogs and opinion pieces. After all that and braving a long commute, life at home is just as hectic.  For these reasons, I haven’t been reading my favorite blogs and posts with regularity. But when I do have the occasional moment to read them, I regularly find posts about the exact things I just complained about. And inevitably,  many conclude with something that goes like this:

” This is not what I signed up for.”

Despite these struggles of the modern physician, I continue to remain optimistic and happy with my career (primary care internist). My ability to cope, stay resilient despite these threats, struggles and challenges is all about perspective. This a perspective that has been forged through a lifetime of experiences, of which my last 6 years as a parent (of 3) has been most paramount to my happiness as a physician.

The joys of parenthood are innumerable. Pick one.

Baby’s first smile. 1st step. 1st words.

Squeezing baby fat. Cute baby dresses. 1st baseball jersey.

1st day of school, playing catch outside, watching a movie together.

This is exactly what I signed up for when I became a dad.

The horrors of parenthood are also plentiful! Pick one.

Sleepless, endless nights. Colic.

Teaching right from wrong or manners, the insanity during bedtime.

Potty training, homework, The teen years.

This is exactly what I did not sign up for when I became a dad…so I thought at first.

But eventually I realized this is what it is to be a parent. The life of a parent, is one of sacrifice and you accept the struggles in order to achieve an important and meaningful outcome. And when you focus on the outcomes and try to recognize the positive moments along the way, you grow more resilient towards all the negative things that come.

I’ve applied this principle to my life as a physician. I don’t need to recount the problems in healthcare. There are plenty of other blogs that catalogue the problems much better than I ever could. But there are also so many good moments.  These are moments that make you laugh, smile, grateful and proud.  And often, I’m tempted in a moment of weakness to try to weigh the good against the bad while trying to answer the question “Why am I here?” That’s when I remind myself, the journey is unpredictable, both up and down. The destination is what really matters.

I want my patients to be well.

I want my kids to be happy.

And as a byproduct of getting them where they need to be, I too will be well and happy.








ACP 2017 Thoughts

This post is a bit overdue.

A couple of weeks ago, I had the opportunity to attend the American College of Physicians annual conference in San Diego, California. Here’s a quick recap and thoughts on the event!

As always, a conference is a welcome respite from our day the day work. It’s fun to get away and see a different city. It’s also a nice way to reconnect with old colleagues and meet new ones. It’s also great for career development, refill and recharge that innate desire to learn and improve yourself. Looking back, I’m happy to say this year’s conference (#IM2017) accomplished all of these things.

There’s plenty of medical conferences to attend every year, and the decision to attend ACP came down to a few things. As an internist, ACP is our largest organization and supporting it, both financially and attendance was the sensible thing to do. The long term health of my field depends on ACP to not only teach us through educational programs, but also advocate for us. Internists in my humble, albeit biased opinion are the linchpins of a successful healthcare system that is struggling fiscally and clinically to take care of patients with chronic illness.

Attending ACP also reflects a shift in my career aspirations. For many years now, my interests in medicine have been varied. I’ve split my time, focusing on how I can make health systems better, how I can make trainees better (students/residents) and how I can make patients better. Fortunately, there are many good conferences out there (SGIM, AAIM) that can help academic physicians improve in all these aspects in one meeting.

But after many years as an academic physician, I’ve decided to consolidate my tripartite missions into the 2 things that initially got me interested in medicine; the science and the patients. And with this renewed sense of direction, ACP’s #IM2017 was a great start towards expanding my clinical knowledge and bringing it back to help improve the lives of my patients.

Despite this shift, there is a part of me that continues to want to work to make health systems better. There’s also a part of me that wants to continue to teach. Although an academic institution is the best place to do these things, I believe it can be done in different practice settings. Though students and residents are only found in academic places, “teaching” patients is just as gratifying!

I’ll always remember ACP #2017 as the start of a new chapter in my career. It was an incredibly enjoyable experience, and one that that reinvigorated my love for medicine and practicing primary care as an internist. I’m really excited to bring the latest in clinical innovation to the variety of wonderful and inspiring patients that I serve every day.

Next year, ACP’s annual meeting is in New Orleans! #IM2018

Shabbir Hossain MD FACP

Blending evidence based medicine with patient-centered care.