Wednesday, December 16, 2015

The most useless thing we routinely teach trainees? A vote for “A&Ox3”

Source: Wikimedia

by: Winston Chiong (@WinstonChiong)

As a neurologist, I read this article and was reminded of one of my pet peeves in how we teach trainees. Rapoport and Rapoport note the ubiquity of starting the mental status examination with an assessment of the patient’s alertness and orientation to “person, place and time.” Orientation to person is supposedly assessed by asking the patient to state his or her own name, and its traditional placement at the start of presenting the physical examination (just after the vital signs) might suggest that this assessment is of high clinical value.

Of course, it’s actually just about useless. A couple really nice quotes from Rapoport and Rapoport:

Unlike other principal components of the neurologic examination, orientation to person does not clearly correspond to a localizable function of the brain or nervous system, and there is no consensus on how it should be tested, what it signifies, and under what circumstances—if ever—it can truly be lost.

Although we have long searched for such a case, from our own experience in examining neurologic and neurosurgical patients, we can provide no example of a conscious patient unable to state or appropriately respond to his or her name—apart from aphasic patients, malingerers, and memorable amnestics romanticized in film and literary fiction. “Orientation to name” is highly resistant to perturbation, even in advanced neurologic disease.

I’ll add that I’ve cared for a handful of patients with transient global amnesia, a fascinating and thankfully temporary condition in which patients are unable to form new memories, repetitively ask where they are and what they’re doing, and are often disoriented to the decade. These patients never forget their names. Similarly, patients with advanced dementia who can no longer correctly identify close family members remember their own names, pretty much as long as they can meaningfully respond to any other question. There are rare psychiatric patients with total autobiographical dissociative amnesia (so I’ve heard), but their presentation is obvious and unusual enough that we don’t need to screen for them in a general examination.  

Thus, when I read or hear that a patient is “alert and oriented to person, place and time” (or worse: “A & O times three”), I tend to assume that the doc reporting this element of the exam is either very green, or lying. Because really, what astute clinician actually asks all of his or her patients to state their own names? Is there any context in which this is even conceivably useful?

So I’m nodding along to Rapoport and Rapoport’s historical discussion of the German origins of examining “orientation to persons” (that is, of the other people around the patient) as part of the patient’s broader awareness of his or her situation, which then got lost in English translation as “orientation to person”—as in, knowledge of one’s own identity and name. But then I got to this shocker at the end:

We advocate that orientation to person (self and own name) and orientation to persons (others and situation) both be assessed in the neurologic examination of mental status. [my emphasis]

What a cop-out! My alternative suggestion: if a component of your examination has no localizing or other diagnostic value, and if reporting that finding communicates nothing about the patient besides the naivete or insincerity of his or her doctor, and if we only got started with this silly practice from a historical and linguistic mistake... maybe you should stop doing it and use your precious examination time for something more useful? And teach your students and other trainees to do the same?


Helen Chen, MD said...

Dr. Chiong raises a good point. I had never really given much thought to the O x 1 (self) that is actually selectable in our EHR (that's a subject for another day). What I have been struck by is the use of A+Ox3 as shorthand during handoffs: "she's totally A and O times 3" is heard from many disciplines. In general, I doubt that the speaker has actually asked any of the orientation questions and I am hopeful that what s/he really means is that the person is not delirious and has capacity, but I know that's a leap of faith.

In addition to highlighting the lack of diagnostic utility, I like to ask our trainees to consider what they would do if called to assess a patient for a mental status change and the only 'cognitive' exam documentation in the chart were A+Ox3. We're geriatricians. We can and should do better than this.

madhusree singh said...

This was a fascinating discussion. AAOx3 is completely uninformative& the time ought to be spent doing something more useful.

Andrew Kamell said...

While I agree about the orientation to person, I strongly disagree with the remainder. The majority of patients with hypoactive delirium are unrecognized and untreated. They can fake simple conversation, but when pushed will tell you that it is 1956 and make up a location. While orientation is not 100% sensitive and not at all specific to delirium (and yes, orientation to self can be assumed) it is a very simple, fast screening tool that (unless you have a better suggestion) is essential for ruling out one of the most serious and underdiagnosed conditions for the elderly. Oriented x 4 (including situation) helps even further, with much of the information needed to determine capacity, another critical assessment.
If you change this post to "a vote for orientation to self," fine. As stated, unless you propose a faster, more accurate screening, I believe this claim is outright harmful.

Minerva said...

Showing my age maybe, but in my day it was "Oriented to TPP". Actually, these days in Australia, the best test of orientation is whether the patient can correctly state the name of one person, that of our Prime Minister. We have had a few lately.