review of systems is positive for looking like a tool
The review of systems (ROS): the clinical catch all that covers everything and nothing at the same time. For the non-medical readership, the “review of systems” is the part of the history that your doctor (or whoever taking the history) takes from you (or any other patient) where he asks about a bunch of seemingly random symptoms that you may have:
Have you had any fevers or chills? Nigtht sweats? Unexpected weight loss/gain? Change in appetite? Sore throat? Runny nose? Chest pain? Difficulty breathing? Cough? Nausea/vomiting? Diarrhea/constipation? Difficulty/burning/pain with urination?
So what is it all about? The point is for the physician to do one last review of all symptoms you may have covering all of the major organ systems (click on the picture for an appropriately thorough ROS checklist). This can be an obviously important part of the history (1) if the physician forgot to ask you about a symptom and (2) because potentially serious medical problems masquerading as more benign processes can sometimes be detected through the presence of specific multi-system symtoms. At least that’s the rationale we’re taught in medical school. In practice, we’re faced many times with patients who have very obvious medical problems. For example, the guy who was just hit by a car and is wheeled into the ER with a broken bone sticking out of his leg. Asking that dude about whether or not he has had a runny nose recently probably won’t be helpful in managing his broken leg. In fact, asking him about a runny nose will probably get a response like “FIX MY FUCKING LEG!!!!”
Another common situation where the review of systems is not always incredibly helpful is for the routine follow-up patient. The patient who has been coming to the same doctor for years for the same health problem that has been stable for years. Sure you ask about symptoms related to the health problem or progression of it but asking about completely unrelated health problems–especially if you are a specialist? Not that helpful most of the time. Don’t get me wrong though–the ROS is very appropriate and can be very helpful in a number of situations but not always. Judge for yourself: asking someone who has been going to the same neurologist for a seizure disorder about diarrhea. Doesn’t seem too relevant to me but then again, you could argue that I don’t know that much yet.
So why does an in-depth ROS happen all of time? Probably billing purposes. That’s a dirty little secret, which we should probably keep to ourselves. And the more systems that are asked about, the more that your physician can bill the insurance company: 5- vs. 7- vs. 11-system ROS. SHOW ME THE MONEY! And while I find this amusing, it’s actually not why I write this post.
I was at a cardiologist’s office recently where the physician’s assistant was talking to a returning patient who has been coming in every six months for a well established history of a benign, episodic arrhythmia. I was sitting there and watched this PA speak to the patient before the cardiologist came in. The PA asked about cardiac- and arrhythmia-related symptoms. And then, the review of systems. Fevers/chills, night sweats, abdominal pain, nausea/vomiting, diarrhea/constipation, even a repeat of the cardiac ROS. And as I was watching, it was so obvious–from my perspective, the patient’s and from the way the PA was asking–that most of these questions were out of place. Moreover, it was also obvious that the PA had no desire to hear “yes”. Trust me, I know the feeling. I mean, what if the patient said something like, “yes, I have a sore throat”? The cardiology PA would’ve said something like, “go see your primary care doctor”.
Anyway, I couldn’t help but wonder, is that what I look/sound like when I’m running through the ROS?
As I said, there’s a time and place for a 5-, 7- or 11-system ROS. But when people try to force it, it just comes across so wrong. Sometimes, you can actually look really smart by asking a seemingly unrelated question–in particular if the answer is “yes”. The patient is like, ”Wow, how did you know? You must be really smart to know that seemingly unrelated symptom is connected to my disease!” In my experience, though, this only works when you know what you are talking about. At least for me. I’ve nailed it a few times when I have a good idea of what the patient has and I know about the multi-system symptomatology that accompanies the disease. If I ask questions blindly and get an occasional hit, the patient will ask something like “Why–does that mean something?” And then I’m stuck sitting there like, “uhhh, I don’t know” or “uhhh, probably not”, in which case I look stupid for asking about something that has nothing to do with why the patient is there.
I hope I don’t get a lot of angry comments about the importance of the ROS–because I don’t disagree. My only point is that there is a time and place for it and the varying levels of depth that one needs to go into–depending on the patient’s history, risk factors, past medical history, family history, etc–there’s a reason why we ask about those things people! Yes every disease can have multi-system symptoms that could be helpful to ask about but how many people with disease X do you ask about symptom Y to get a positive hit? 100? 1,000? 1,000,000? At some point, you have to balance the 24 hours in a day with the desire for thorough patient care.
I can’t help but wonder if I look like as big of a tool as the PA when I’m running through the 11-system ROS on someone who came in for a dermatology follow-up on their acne. In the last year, I have been using some clinical judgement in regards to how much of an ROS I go through with patients. I’ve generally gotten very little flak about it, which is helping me build up some confidence that I’m asking the right questions in a focused history. (Is it possible I’m learning something?!?!?). Sometimes, I just gotta bite the bullet and do it for billing purposes (every service is different), so I do it. But I can’t help but feel like a real tool when I’m doing it that way–sort of seems like abandoning clinical judgement for the judgement of insurance companies–and the patient can tell too.
What are you gonna do though? That’s medicine: a balance of time, efficiency, patient care, and getting paid. All very important, but I don’t even want to get into that now. In any case, next time you go to see a physician, someone takes a history from you and ends it by asking about a hodgepodge of symptoms, you can (1) ask for a justification for asking about such symptoms–”why, is blood in my urine related to my needing refills on my seasonal allergy medications?”, (2) ask how many systems they have to probe in their ROS for billing the insurance company or (3) be nice and not give anyone a hard time. If by chance you see me, the answer better be choice #3. But then again, it could just be karma biting me on the ass for bringing this up to begin with.