A Country Doctor Reads: July 6, 2019

Time and the Choice to Listen

This week, again, I ran into a couple of articles about the inordinate amount of time doctors spend on charting and reading chart notes. Each of my reads made the point that it is better to listen to the patient.

When you find yourself in a position of rendering a second opinion, do you read through old notes and test reports or do you put all that aside and listen to the patient tell their story from the beginning?

Osler himself said “Listen to your patient, he is telling you the diagnosis”.

Raphael Rush, MD, has a thoughtful essay in The New England Journal of Medicine, titled “Taking Note”:

I turned my chair away from the computer and angled toward her. My stethoscope weighed on my neck and I removed it, along with my smudged glasses, which forced me to lean in. I picked up a pen and some paper, ready to transcribe whatever she said.

After a moment, she took off her jacket and settled into her chair, resting her coffee cup down on my desk. She seemed to relax. I confirmed her name and date of birth, and then we began.

“I have a lot of records from your other doctors,” I said. “We’ll review those together in a bit. But I want to hear your story again, in your own words, if that’s OK. From the beginning.”

http://www.nejm.org/doi/full/10.1056/NEJMp1816537

JAMA Network Open featured a piece this spring by Pieterse and colleagues titled “Shared Decision Making and the Importance of Time”

Clinical encounters, although uncommon in the lives of many patients, offer a place and time for clinicians to gather insight into what matters to each patient and for patients and clinicians to co-create care that fits each patient’s situation. Time during encounters is usually set by the schedule, which is the result of algorithms that prioritize meeting the demand for access to available clinicians over offering enough time for unhurried consultations. The completion of recommended tasks and of clinical and administrative documentation further taxes the time in consultations. Clinicians often feel hurried and interrupt the conversation with a patient, on average, within 11 seconds.4 When lacking time, clinicians may present information with a complexity or tempo that may easily overwhelm the attention of patients who are ill and worried. Information is then lost on patients, and time is wasted. Clinicians may not allow for a silent pause and miss key patient disclosures or questions.

Conversely, wresting unhurried visits from a system that overbooks clinicians occurs by accident, such as, for example, when a patient does not show up for a visit, or requires a conspiracy between patients and clinicians to lengthen the visit and spend the necessary time together. The resulting delay may offend other patients who are waiting and frustrate the staff who will have to stay late at work.

https://jamanetwork.com/journals/jama/fullarticle/2731737

And in my own archives I have a piece from 2017, titled “Did You Read My Chart?” about a woman with a chronic problem I saw one busy Saturday (No, I did not read it):

https://acountrydoctorwrites.blog/2017/02/28/did-you-read-my-chart/

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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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