How Doctors Think

Giving a verbal report at the hospital is an art form. You want to be able to tell a story clearly and with brevity and nuance so you can accurately convey the issues the patient presents. You want to encapsulate the entirety of your physical exam, history, treatment and thirty minutes spent with the patient so the patient can be properly placed in the appropriate hospital area and treated with the appropriate concern.

I have found it frustrating lately to discover a number of hospitals have introduced computers to their triage areas. Where before, the triage nurse looked you in the eye and listened to your thirty to sixty second report, they now stare at their computer screen and have you slowly dictate the patient’s name and then date of birth, and then list the complaint, as they manipulate the computer mouse or hunt and peck at the keyboard. The report still gets done, but it is more disjointed. I feel like saying to them, you ask me the questions you want to know, and I’ll tell you, rather than me attempting to give any kind of narrative. I get frustrated because “the chest pain” may not be just a chest pain.

I was mentioning this to a fellow EMT when she took out a book she was reading and read me the following passage:

“Electronic technology can help organize vast clinical information and make it more accessible, but it can also drive a wedge between doctor and patient when used in this way to increase “efficiency.” It also risks more cognitive errors, because the doctor’s mind is set on filling in the blanks on the template. He is less likely to engage in open-ended questioning, and may be deterred from focusing on data that do not fit the template.”

The passage is from a new book, How Doctors Think? by Jerome Groopman, M.D. that is a fascinating read. I recommend it to EMS providers to help understand how the modern health care system, its finance practices and time constraints can affect patient care.

(In EMS, I have never felt subject to financial constraints, but I do feel time constraints — I need to get through this call and be available for the next one.)

The author talks about how health care providers diagnose through pattern recognition, but how this sometimes can keep us from considering a broader picture. He also talks about the dangers of the “monotony of the mundane.” The flu is not always the flu.

I know I too often write my run form as I question a patient, that in “typical” calls where I have already decided what the problem is, I often ask only the questions that I need to get the answers I need to complete my report and I get impatient when the patient wanders. I often jump to conclusions on what is wrong based on pattern recognition and can tend to ignore a different story that the patient may be trying to tell.

As I wish that the nurse would listen to me instead of looking at her computer screen and trying to pigeon hole the patient into a defined category, I need to listen more to the patient instead of writing my run form, and that instead of going always with my first impression, I need to listen more to the story the patient is trying to tell. They may not be practiced in giving a perfect thirty to sixty second short story, but it will be my job to condense their story once I have gotten it out of them. I need to ask more, “What do you think is wrong?”

Early in the book, the author mentions the famous doctor William Osler who believed that if only you listen, the patient will tell you the diagnosis.

In the final chapter, the author writes:

“A doctor’s office is not an assembly line. Turning it into one is a sure way to blunt communication, foster mistakes, and rupture the partnership between patient and physician. A doctor can’t think with one eye on the clock and another on the computer screen…(I have) a vital partner who helps improve my thinking, a partner who may, with a few pertinent and focused questions, protect me from the cascade of cognitive pitfalls that cause misguided care. That partner is present in the moment when flesh-and-blood decision-making occurs. That partner is my patient or her family member or friend…”

4 Comments

  • Medicmarch. says:

    We’re lucky down on my end because although the ER does have the computer entry and all that jazz, the nurses mostly still listen to us. We are no required to leave a copy of our run report with the facility staff so they can “see what we see” – assuming our documentation skills are up to snuff.

  • Keyur says:

    The title of the blog is quite interesting. Even the whole blog is awesome. I was just searching such blog for my site.Thanx & Regards,ASP Senna Traders

  • Loving Annie says:

    Computers can miss too much… It makes for good bureaucracy and not always well-covered patient care.Docs are overwhelmed, but getting to ask open-ended questions of the patient and to TALK is way more important than filling in the blanks to cya.Technology isn’t always a gift.

  • Anonymous says:

    Doing my medic ride time at a hospital based system I see things much different then at home in a third servic setting. The nurses normally respect us, we see the docs all the time and they will often give us first crack at ER intubations. When it comes to reports we give them as the nurse scribes them on the ER flow sheet and for the most part they listen to what you have to say. What bothers me most are the hospitals where the nurses write your stuff on a paper towl…as if they were so busy as to find a real peice of paper.

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