Talk, Think, Listen and Type

Four and a half years ago I read an editorial in JAMA, the Journal of the American Medical Association, that etched a short phrase into my memory. These five words seemed so profound and poignant that I really think they almost define primary care medicine today, perhaps with the alliterative addition of the word “teach”.

Dr. Abigail Zuger wrote of how the computer had changed the dynamic in the exam room and of the communication skills physicians now need to master:

“The physician will know the highly technical vocabulary of relevant research agendas well enough to encourage patients to get involved. The physician will also keep up with popular culture, tracking popular direct-to-patient communications and incorporating them into the clinical dialogue. In addition, and most importantly, the physician will have virtuoso data entry and retrieval skills, with an ability to talk, think, listen, and type at the same time rivaling that of court reporters, simultaneous interpreters, and journalists on deadline. The physician will do all of this efficiently and effectively through dozens of clinical encounters a day, each one couched in a slightly different vernacular.”

We’ve come a long way since Sir William Osler advised “Look wise, say nothing and grunt”. In his day, arriving at the right diagnosis was the most important task of a physician. Treatment options were usually limited. Today, even the most mundane diagnosis has myriads of treatment options. And in spite of all the advances of medicine, today’s false prophets and practitioners promote the medical equivalents of “alternative truths”. This is where the “teach” comes in. In rural medicine in particular, the village doctor may be the most learned person for miles around and we do need to promote scientific common sense to our patients and our communities.

Back to Dr Zuger’s quote:

I love the comparison of a physician’s work with court reporters, interpreters and journalists on a deadline. Our need for accuracy is obvious, and an interpreter truly needs to be familiar with both languages; even before I moved to this country I could spot the translation errors in the subtitles of American movies on Swedish television. You probably have to spend some time here to know that a six pack is a quantity of beer, and that half and half is a coffee whitener made up of half milk and half cream. Similarly, we have to be familiar with the worlds and cultures our patients live in. And the time pressures of primary care are obvious.

The ability to listen at the same time as we talk or think about what we want to say is essential if we want to be patient centered. We need to be exquisitely sensitive to our patients’ verbal and nonverbal communication if we are going to be any help to them.

And, as far as the typing goes, I actually do better on the iPad’s virtual keyboard with autocorrect than on a conventional keyboard, especially one with great “travel” of the keys and manual spellchecking (in my case type-checking; my spelling is fine). Then, of course, there is Dragon, Siri, and on my mini, the ultimate two-thumb typing.

And just like Dr. Zuger suggests in her editorial, the iPad allows me to pull up next to my patient so we can both see the reports, lab tests and the evolving office note that we, in many ways, create together.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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