Posts tagged “doctor”

Keeping the Humanity in our Technology Work

A few articles about the practice of medicine echo each other in significant ways, but I share them here as a reminder that all of our work that increasingly relies on technology (e.g., developing digital products) will suffer terribly if we fail to engage the human who thinks, talks, listens and tells stories.

With Electronic Medical Records, Doctors Read When They Should Talk

Even if all the redundant clinical information sitting on hospital servers everywhere were error-free, and even if excellent software made it all reasonably accessible, doctors and nurses still shouldn’t be spending their time reading. The first thing medical students learn is the value of a full history taken directly from the patient. The process takes them hours. Experience whittles that time down by a bit, but it always remains a substantial chunk that some feel is best devoted to more lucrative activities.

Enter various efficiency-promoting endeavors. One of the most durable has been the multipage health questionnaire for patients to complete on a clipboard before most outpatient visits. Why should the doctor expensively scribble down information when the patient can do a little free secretarial work instead? Alas, beware the doctor who does not review that questionnaire with you very carefully, taking an active interest in every little check mark. It turns out that the pathway into the medical brain, like most brains, is far more reliable when it runs from the hand than from the eye. Force the doctor to take notes, and the doctor will usually remember. Ask the doctor to read, and the doctor will scan, skip, elide, omit and often forget.

Like good police work, good medicine depends on deliberate, inefficient, plodding, expensive repetition. No system of data management will ever replace it.

Why Doctors Need Stories

I have long felt isolated in this position, embracing stories, which is why I warm to the possibility that the vignette is making a comeback. This summer, Oxford University Press began publishing a journal devoted to case reports. And this month, in an unusual move, the New England Journal of Medicine opened an issue with a case history involving a troubled mother, daughter and grandson. The contributors write: “Data are important, of course, but numbers sometimes imply an order to what is happening that can be misleading. Stories are better at capturing a different type of ‘big picture.’ ”

Beyond its roles as illustration, affirmation, hypothesis-builder and low-level guidance for practice, storytelling can act as a modest counterbalance to a straitened understanding of evidence. Thoughtful doctors consider data, accompanying narrative, plausibility and, yes, clinical anecdote in their decision making. To put the same matter differently, evidence-based medicine, properly enacted, is judgment-based medicine in which randomized trials, carefully assessed, are given their due.

I don’t think that psychiatry — or, again, medicine in general — need be apologetic about this state of affairs. Our substantial formal findings require integration. The danger is in pretending otherwise. It would be unfortunate if psychiatry moved fully — prematurely — to squeeze the art out of its science. And it would be unfortunate if we marginalized the case vignette. We need storytelling, to set us in the clinical moment, remind us of the variety of human experience and enrich our judgment.

From October 2003, Diagnosis Goes Low Tech

“This technology has become a religion within the medical community,” said Dr. Jerry Vannatta, former dean of the University of Oklahoma College of Medicine. “It is easy to lose sight of the fact that still, in the 21st century, it is believed that 80 to 85 percent of the diagnosis is in the patient’s story.”

Yet medical educators say that doctors are insufficiently trained to listen to those stories. After all, there is no reimbursement category on insurance forms for it. It is this lost art of listening to the patient that has been the inspiration behind a burgeoning movement in medical schools throughout the country: narrative medicine.

The idea that medical students need an academic discipline to teach them how to listen may strike some as farfetched. After all, what should be more natural — or uncomplicated — than having a conversation?

But the narrative medicine movement is part of an ongoing trend in exposing medical students to the humanities. It is needed, educators say, to teach aspiring doctors to pay close attention to what their patients are saying and to understand the way their own emotions affect their perceptions, and ultimately their clinical practice.

The basic teaching method is to have medical students read literary texts and then write about themselves and their patients in ordinary language, rather than in the technological lexicon of the traditional patient chart.

Venerable medical journals like The Journal of the American Medical Association and Annals of Internal Medicine are increasingly publishing reflective writing by doctors, their editors say. And now some medical schools even have their own literary journals. At Columbia University College of Physicians and Surgeons, there is Reflexions; Pennsylvania State University College of Medicine publishes Wild Onions; at the University of New Mexico’s Health Sciences Center, there is The Medical Muse.

Columbia also publishes a semiannual scholarly journal devoted solely to narrative medicine, titled Literature and Medicine, which is edited by Maura Spiegel, a literary scholar, and Dr. Rita Charon, a professor at the medical school and a founder of the narrative medicine movement.

Doug’s War Story: Knock-knock! Who’s there?

Doug Cooke is founder of Tinder, a research consultancy focused on people-centered innovation.

In a recent research and strategy project focused on defining a new global platform for a medical device, our research plan required us to shadow clinicians and others as they used existing devices in the “context of care.” With minor issues like HIPAA protecting patient privacy and other security issues at big urban hospitals in the US, our team decided that conducting research in Europe provided a better opportunity to understand these devices and their users.

Planning started with all the usual steps: multi-day client sessions to assess the domain, issues and problems; auditing reams of client data and documents; becoming familiar with competitive products, etc. We developed a research protocol that went through many rounds of revision with a large, multi-location client team, arriving at a clear understanding of relevant and important user issues. We developed screening criteria for participating medial institutions. Pilot studies were run at US hospitals. Months of preparation were spent in making sure our research team was fully prepared to bring back insights and perspectives that would help define the next generation global respirator platform. Ready, set, on to Europe!

Our first stop was a hospital in Wales. They had lined up the appropriate people for us to shadow and interview, including department heads, physicians, and medical techs. We spent two days shadowing, probing and gathering, and everything worked according to plan. Wahoo!

At our second stop in London (hauling two large model cases that would not fit into London’s very spacious cabs), we arrived at the check-in desk and ask to see Dr. Smith (or so we’ll call him). Upon arrival at his department wing, we learned that Dr. Smith was not in. Even more concerning was that Dr. Smith was out of the country at a conference and had not let anyone else know we were coming. After speaking with a few more people, the answer was “Please come back at another time when the doctor is in.” Ouch! In spite of all the planning, effort, and resources to get here, a few uncooperative people were about to jeopardize our research program.

How could this happen? Well, I ignored one of my primary rules: never let the client take on a critical path item that could endanger the project’s success and my firm’s reputation. Specifically, because of the difficulty of gaining access to the right people and institutions, and extremely high cost if we were to use a traditional recruiting process, our client took on the responsibility for arranging our visits to hospitals through Europe. Few clients understand the level of effort needed to screen, schedule and triple-confirm each participant. When the “research gig” is complex and requires the participation of a number of people carefully choreographed in a short time, it is essential to have a dedicated, experienced resource to make that happen.

We made it all work in the end. With no Dr. Smith and an apparent dead end, we literally started on-the-spot networking, walking up and introducing ourselves to doctor after doctor until we had made some friends that would grant us two days of access in the ICU and ER. It worked out in the end, but presented unforeseen delays and stress to an already pressure-filled project. Painful but constructive outcomes, nonetheless.

The rest of the trip in Germany and Italy presented various levels of preparedness on the part of hospitals we visited. Some hospitals were planning on hosting us for our full two day itinerary and some were expecting only a few hours meeting (which we were able to extend by turning on our best charm).

I have always been a very careful planner and can fastidiously orchestrate research logistics. I know what it takes to gather user insights. But the lessons learned from this European research foray is a clear reminders that whenever I can, I must control the recruiting and scheduling process. I hope to never again knock on any unsuspecting doors.

ChittahChattah Quickies

  • The process of converting books to Kindle format introduces errors in the text – The cost of a printed book covers some degree of proofing and checking—not enough, but some. The cost of a Kindle book does not support editorial quality control, and the multi-step conversion process, handled in bulk by third parties, chops out content and creates other errors that no one fixes because no one is there to do QA.

    As the economics of publishing continues to change, perhaps one day soon, a Kindle edition will contain the same text as the printed book. Until it does, Kindle is great for light reading. But if it’s critical that every word, comma, and code sample come through intact, for now, you’re better off with print.

  • The Social History of the MP3 – For Reading Ahead, we're looking at other transitions to digital: "So omnipresent have these discussions become, in fact, that it's possible the past 10 years could become the first decade of pop music to be remembered by history for its musical technology rather than the actual music itself. This is a chastening thought, but at the same time we have to be careful not to overlook how the technologies we invent to deliver music also work to shape our perception of it. When radio came along, its broadcasts created communities of music-listening strangers, physically distant from each other but connected through the knowledge that they were listening to the same song at the same time. Where radio brought listeners together as a listening public, the LP started splitting them apart. The LP and 45 rpm formats took the phonograph, which had been in existence for over half a century, to the masses, right as the American middle-class was going suburban and privatizing their lives."
  • Medical Students Experience Life as Nursing Home Patients – Students are given a “diagnosis” of an ailment and expected to live as someone with the condition does. They keep a daily journal chronicling their experiences and, in most cases, debunking their preconceived notions.

    To Dr. Gugliucci’s surprise, she found nursing homes in the region that were willing to participate and students who were willing to volunteer. No money is exchanged between the school and nursing homes, and the homes agree to treat students like regular patients.

    “My motivation is really to have somebody from the inside tell us what it’s like to be a resident,” said Rita Morgan, administrator of the Sarah Neuman Center for Healthcare and Rehabilitation here, one of the four campuses of Jewish Home Lifecare.

ChittahChattah Quickies

  • The Computer Will See You Now – how the computer interferes with the doctor-patient interaction – Doctors struggle daily to figure out a way to keep the computer from interfering with what should be going on in the exam room — making that crucial connection between doctor and patient. I find myself apologizing often, as I stare at a series of questions and boxes to be clicked on the screen and try to adapt them to the patient sitting before me. I am forced to bring up questions in the order they appear, to ask the parents of a laughing 2-year-old if she is “in pain,” and to restrain my potty mouth when the computer malfunctions or the screen locks up.

    The computer depersonalizes medicine. It ignores nuances that we do not measure but clearly influence care. Room is provided for text, but in the computer’s font, important points often get lost.

    A box clicked unintentionally is as detrimental as an order written illegibly — maybe worse because it looks official. It takes more effort and thought to write a prescription than to pull up a menu of medications and click a box.

  • Tension between medical and colloquial language – an issue I explored in interactions column (Poets, Priests, and Politicians) – (via MeFi) Dr Ardill, in evidence, said he did not use the words alleged by Ms McQuade. He said he asked her was she “next or near a man’s willy bits” in the last six months and in relation to her sleeping he did suggest a drink, light exercise, a trashy novel or some “rumpy pumpy”. He said he used this kind of “childish” language with all patients to make them feel at ease. Nobody before had found it offensive. He said he would not use the term “willy bits” again.


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