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This is the biggest fear I or, for that matter, any medical student faces in the clinical exam in India.(Based on true events)The scenario: you are giving one of the toughest exams of your life. Facing an examiner you have never seen and probably answering questions you have never heard before. (If it is more of the latter, God save you).The patient's history is taken in rapid detail and examination is completed. 45 minutes is all you get. The patient is either a regular fare at such exams with a chronic disease like SLE or cardiac valvular disease, visiting exams for the past 10 years, and knows about his case probably more than you. Or, he is a complete newbie and has been thoroughly irritated by the multiple examinations in the last 2 days of the exam.Then, you take your clumsily written history sheet to the grim, moustachioed, frowning and forbidding examiner, who looks like he last smiled on the day of his wedding.Event 1:Examiner: what is your case?Student: s..sir, pain in the right hypochondrium for last 3 months.Veteran patient: but sir i have pain for last 6 months.(Please understand that you are not at fault here. Some veteran patients have their own bit of fun during the exams).Student: exactly sir! Pain for last 6 months which has exacerbated for last 3 months. I was coming to it in history of present illness!Veteran patient and student exchange glances.Event 2Examiner: history please.S: a 30 year old male with pain in the right iliac fossa…. Completes history…E: (to the patient) so where is your pain?Irritated Patient: (pointing to epigastrium) here sir!Examiner frowns and looks at you like you have just asked for his kidneys….S: (to the patient) but isn't that pain mild? Didn't you say it is mainly gaseous bloating? Weren't you having severe pain for the last 1 month here (pointing to right iliac fossa)? If you don't tell sir everything properly, your treatment will erroneous! Remember! Tell sir where you exactly have the pain! ( Points to the iliac fossa while asking)Irritated Patient: actually sir. He is right sir. I have pain here but some bloating here too. All these boys have been pressing my stomach for the last 2 days.(You breathe a sigh of relief as the examiner's frown decreases by 20 percent).So, to summarize, there is really no quip you can use to salvage a history changing patient. You are giving the exam like your life depends on it. Rather than a comeback, you need a life saver and quick thinking. My experience/suggestions are:Never change the patient's history. Ever. Period. Try to fit the reasoning to the history. Not vice versa.Never argue with the examiner. What he says is gospel fact. You must accept that you are suresh if he calls you that, even if you are ramesh. Just make sure he gets your roll number right.Reinforce the patient's history during your examination. Repeatedly ask and tell him, while pointing to the area that he has spoken about. This will decrease chances of a change.Never try to act smart with the examiner. He holds the pen that passes the judgement to hang you.Be confident. Never get flustered and stammer.Respect the patient and respect his body. Examine him gently. Make him comfortable and always treat him well. He is your biggest teacher. The better your rapport with the patient, the lesser the chances of a surprise during the presentation.Impress on the patient that a correct history will ensure correct treatment. Wrong history will confuse the big doctor from outside the state. (Doesn't work on veteran patients)Don't get afraid. The examiner can sense your fear. He can feed on it. Literally. The patient too loses confidence in you.One thing that i firmly believe is that case presentation is an art form of the highest degree. You may be an excellent student with wonderful memory, but it can all go south during your case!Best of luck!

There are many (many) reasons - so I'll list a few of the ones that I can think of off-hand.Here in the U.S. - we have a multi-party system: Provider-Payer-Patient (unlike other countries that have either a single payer - or universal coverage - or both). Given all the competing interests - at various times - incentives are often mis-aligned around the sharing of actual patient dataThose mis-aligned incentives have not, historically, focused on patient-centered solutions. That's starting to change - but slowly - and only fairly recently.Small practices are the proverbial "last mile" in healthcare - so many are still paper basedThere are still tens/hundreds of thousands of small practices (1-9 docs) - and a lot of healthcare is still delivered through the small practice demographicThere are many types of specialties - and practice types - and they have different needs around patient data (an optometrist's needs are different from a dentist - which is different from a cardiologist)Both sides of the equation - doctors and patients - are very mobile (we move, change employers - doctors move, change practices) - and there is no "centralized" data store with each persons digitized health information.As we move and age - and unless we have a chronic condition - our health data can become relatively obsolete - fairly quickly (lab results from a year ago are of limited use today)Most of us (in terms of the population as a whole) are only infrequent users of the healthcare system more broadly (cold, flu, stomach, UTI etc....). In other words, we're pretty healthy, so issues around healthcare (and it's use) is a lower priorityThere is a significant loss of productivity when a practice moves from paper to electronic health records (thus the government "stimulus" funding - which is working - but still a long way to go)The penalties for PHI data breach under HIPAA are significant - so there has been a reluctance/fear to rely on electronic data. This is also why the vast majority of data breaches are paper-based (typically USPS)This is why solutions like Google Health - and Revolution Health before them - failed - and closed completely (as in please remove your data - the service will no longer be available)All of which are contributing factors to why the U.S. Healthcare System looks like this:===============Chart Source: Mary Meeker - USA, Inc. (2011) - link here:http://www.kpcb.com/insights/usa-inc-full-report

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