“Oh, how I remember the Review of Systems!”

By | January 28, 2023

Despite being out of direct patient care since 2006, I still can recite the entire review of systems (ROS) in five seconds flat. In fact, our instructors indoctrinated in us that if this documentation did not occur at every visit, one could not fulfill billing and coding requirements. Of course, this was also not the intended purpose of the ROS. Instead, the intent was to ensure a thorough review of possible complaints and conditions, continuity of care as answers might shift over time, coordination of information between clinicians, and improved transparency with patients as records became more available to them.

However, as occasionally happens with good intentions, these lacked validity. Although designed to improve care, and improve documentation, ROS lacked evidence for benefit and inadvertently risked some harm. Moreover, they were time-consuming for the patient as forms were created for patients to fill out prior to their visit Additionally, they diverted attention and time during visits that could have focused on more essential conversations concerning the current problem or health issue. Answers could lead to unnecessary workups. Most of us can remember a finding of importance while performing the ROS ritual; however, there were also numerous times it caused harm and was ineffective.

In January 2021, to simplify visit reimbursement and remove activities that have less importance, documentation requirements for reimbursement morphed into a focus on the complexity of the medical conditions and medical decision-making by the clinician, along with time spent. Resulting in less of a  need to document ROS. This change was lauded by clinicians.  But the questions arises, did this modify our behaviors? As one might expect and likely have recently encountered, the ROS is still alive and well. We, as patients, continue to fill out the forms, and documentation of ROS continues. Interestingly, as our focus is on increasing our face time with patients and implementing more of a consumer-centric model, why do we have such issues with de-adopting activities that are felt to be unfavorable and are not associated with evidence-based improvement of care?

Human behavior and change theories are fundamental to adopting new methodologies. Just as time with the patient might be increased by removing ROS, it may also lead to avoiding certain critical conversations; thus, creating a blame situation rather than adjusting our focus to more meaningful discussions, like behavioral health counseling, shared decision-making conversations, and the time asking questions like, “what worries you the most,” etc.

Of greater likelihood is that human nature maintains habits even though they might not be good for us. The habit cycle of cue/routine/reward must be broken and re-established differently. This endeavor takes time and energy. Each component of the cycle must be addressed, and time must be spent on creating a new habit cycle. Interestingly, it is said that it takes approximately three weeks to create a habit.

We need to step back and really consider how de-adoption should occur, how to fill accrued time with more proven conversations, thus creating a new habit cycle, and evaluate other time-saving activities.  The lack of time spent with a patient is massively dissatisfying for clinicians and consumers. Let us focus on utilizing our time wisely and embracing more fruitful conversations. Additionally, let us embrace the changes we have lobbied for; otherwise, others will glance at us and proclaim, “why should I be the one to change anything since you are not?”