Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

Swerlick, Robert A rswerli at EMORY.EDU
Mon Jan 12 16:52:26 UTC 2015


We cannot view history taking isolated from all the other tasks we undertake and the context in which it happens.

One of the huge barriers to effective care delivery is a work flow which pushes us to attempt to do too many tasks at the same time. What I mean by this is our current approaches, especially in the outpatient setting, is that we attempt to collect data (history taking is part of this), synthesize data, make decisions, communicate decisions, and generate a report, all at the same time.  It is simply not possible to do this effectively. No amount of training can fix this either.

I believe that Larry Weed made this observation forty years ago and he proposed that the data collection piece needs to be segmented off in time and that it is essential to collect a complete and standardized dataset before you can begin to undertake all these other tasks. I think one can inject the art of history taking into the process only after one has collected a minimum, rules based standard data set as a starting point.  We are much better prepared to listen to patient stories if we already have collected key elements of history ahead of time and had them presented to us in a format which puts valuable elements in front of us in such a way that we recognize them.

Smart questionnaires can be constructed and administered to patients in time frames which are much more immune to time pressures which drive incomplete data collection and premature closure of the diagnostic process. Even though I use rather rudimentary survey tools I have found that I can be much more effective in connecting with patients when I walk into the room actually prepared. When we move to the next stage of deployment and the survey actually populates the HPI it will also relieve me of  a huge documentation burden, freeing even more time for me to do more high value functions.

Using standardized histories will also allow us to identify which elements of history are actually most valuable. When I hear about how history taking is an art, I can't help but think of Josh Wennberg's book "Measuring Medicine" where he asked ENT surgeons about what elements of the history and exam were most critical in deciding whether tonsillectomy was indicated. Everyone had their own opinion which they defended.  These criteria led to huge practice variations. A core set of standard history questions asked by everyone and collected in a standard format ultimately allows us to figure out what is valuable.

Bob Swerlick

From: Thomas, Eric [mailto:Eric.Thomas at UTH.TMC.EDU]
Sent: Monday, January 12, 2015 11:26 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

As long as we are taking sides :) , I'll also side with Bob and Ed.  Ed's bridge analogy is good.  With patients you almost never have a clear view of all the facts.  This is especially true in primary care, less so in some subspecialties.  So although medicine can benefit from more standardization I am skeptical that history taking can be rule-based.  Partly rule-based yes, but ultimately there is a degree of subjectivity, complexity, misinformation, misunderstanding, and "art" that occurs between a doctor and patient that defies logic.

I never cease to be amazed by the way patients describe how they feel, how they are selective about information they provide me, how they understand what is wrong and why....the list goes on and on.  I rarely have all the "facts" and a rule-based tool to collect the facts would only take me a few steps in to this maze.  And by the way, I don't find this maze frustrating, I find it endlessly rewarding to try and understand my patients and to help them.

I think Lisa Rosenbaum's recent essay in the New England Journal helps illustrate part of this complex nature of patient-doctor communication by providing a rich and fascinating glimpse into patient beliefs about taking medicines for heart disease: http://www.nejm.org/doi/full/10.1056/NEJMms1409015?query=featured_home

Best,

Eric

Eric J Thomas MD, MPH
Professor of Medicine
Associate Dean for Healthcare Quality
Director, UT Houston-Memorial Hermann Center for Healthcare Quality and Safety
The University of Texas Medical School at Houston
6410 Fannin UPB 1100.44
Houston, TX 77030
713-500-7958
www.utpatientsafety.org<http://www.utpatientsafety.org/>
https://twitter.com/EJThomas_safety







From: Hoffer, Edward P.,M.D. [mailto:EHOFFER at MGH.HARVARD.EDU]
Sent: Monday, January 12, 2015 6:03 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

Indeed, as an MIT grad who planned to be an engineer, I must side with Dr. Centor.  If you are tasked to build a bridge, virtually all of the parameters are defined. The bridge will go from A to B [unless perhaps it is in Alaska  :)], it will carry vehicles of up to X tons with a fudge factor for truckers who disobey posted limits; the average and maximum recorded wind velocity are known, etc.

When faced with a patient with an undefined illness, you must strike a balance between letting them tell their story and guiding the history when they are clearly going off on irrelevant tangents; you must have or establish enough rapport that they will tell you things that might be embarrassing or uncomfortable; you must know enough to ask about things that have not brought up that are suggested by what they have; you must be able to interpret what they tell you about past medical encounters and tests.  MUCH harder.

Ed

Edward P Hoffer MD, FACC, FACP
Associate Clinical Professor of Medicine, Harvard

From: Swerlick, Robert A [mailto:rswerli at EMORY.EDU]
Sent: Sunday, January 11, 2015 7:59 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

A test to show whether you are correct?

Robert A. Swerlick, MD
Alicia Leizman Stonecipher Chair of Dermatology
Professor and Chairman, Department of Dermatology
Emory University School of Medicine
404-727-3669
________________________________
From: Robert M Centor [rcentor at UAB.EDU]
Sent: Sunday, January 11, 2015 4:47 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"
I must disagree.  The art is in the data collection.  Taking a history is much more complex than asking a list of questions.  Each question has many branch points depending upon how one interprets the words, the body language, and the patient's context.

I do believe that this process requires artistry.  What am I missing?
==============

Robert M Centor, MD, MACP

Regional Dean, UAB Huntsville Regional Medical Campus
301 Governors Drive
Huntsville, AL 35801

Office: 256-539-7757
Fax: 256-551-4451

Chair, ACP Board of Regents

Professor, General Internal Medicine
UAB
FOT 720
1530 3rd Ave S
Birmingham, AL 35294-3407


From: Alan Morris <Alan.Morris at IMAIL.ORG<mailto:Alan.Morris at IMAIL.ORG>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Alan Morris <Alan.Morris at IMAIL.ORG<mailto:Alan.Morris at IMAIL.ORG>>
Date: Sunday, January 11, 2015 at 10:44 AM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

Beo Centor makes the argument that medical diagnosis is "science" plus "art," and cannot be more like engineering  Science and art are two broad terms that can have multiple meanings, the specific definitions of which determine subsequent argument.  The science of medicine at the patient-clinician encounter is flimsy.  Replicable methods are rarely pursued.  The art of medicine is sometimes uses as a wastebasket for the remarkable achievements of accomplished clinicians (e.g., William Osler) while ignoring his admonition that method is required for all but geniuses.

I believe Dr. Centor has confounded two constructs that are frequently not adequately identified and separated:

  1.  System of interest:   Sick patients are more complex than mechanical or electrical systems.  A patient, for example, is much more complex than an airplane.  This leads many to conclude that engineering solutions, like those in airplanes, cannot be done in medicine.  However, the human decision-maker (and his/her cognitive limitations) is common to both systems.
  2.  Human decision-maker cognitive limits (4±1 constructs in short-term memory before decisions become degraded):  The clinician decision-maker and the pilot decision-maker are both cognitively limited by the same amount - and they are both overloaded by information.  Pilots can enjoy the benefit of autopilot programs, because the engineers have invested the effort to understand the control needs of airplanes.  We can clearly do the same for clinician decision-makers - feasibility is well-established - but the medical community is so married to the "cottage industry" model of the independent clinician decision-maker that we have not invested the effort to establish and scale autopilots for clinicians.
Healthcare challenges require a combination of autopilot and independent clinician decision-maker (cottage industry).  We seem to be making precious little progress with this combination.  I know of no systematic effort to pursue scaling of autopilot programs in medicine.  This may, in part, be what led Eric Topol, MD to claim that medicine is so conservative, its thinking is ossified.

Alan
Alan H. Morris, M.D.
Professor of Medicine
Adjunct Prof. of Medical Informatics
University of Utah

Director of Research
Pulmonary/Critical Care Division
Sorenson Heart & Lung Center - 6th Floor
Intermountain Medical Center
5121 South Cottonwood Street
Murray, Utah  84157-7000, USA

Office Phone: 801-507-4603
Mobile Phone: 801-718-1283

From: Robert M Centor <rcentor at UAB.EDU<mailto:rcentor at UAB.EDU>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Robert M Centor <rcentor at UAB.EDU<mailto:rcentor at UAB.EDU>>
Date: Sunday, January 11, 2015 at 7:59 AM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

Bob Latino asks an important question.  To rephrase - why cannot medicine be more like engineering?

Patients experience the same disease in many different ways.  They relate different symptoms and have different physical findings and laboratory tests.

The history gives us the greatest challenge.  Patients describe their symptoms in different ways.  Some patients deny their symptoms.  Some patients exaggerate their symptoms.  The great historian needs the art of reading between the lines.  We read body language.  We know when to seek additional information from family members or friends.

If we enter the proper data into our computer (either our biological computer or a program someone else has written) then we often (but not always) get to the correct diagnosis.

Additionally, while some patients follow Occam's Razor, having a single cause for their symptoms, other follow Hickam's Dictum (a patient can have as many diagnoses as he/she damn well please).  When patients have shortness of breath, we ask if the heart, lungs, muscles, etc are causing the symptoms.  Many patients have multiple diseases.  Are the new symptoms due to their known diseases or an additional new problem.

I therefore believe the diagnosis brilliance combines the science and the art.  The great diagnosticians spend much time using system 1 thinking and know when and how to proceed to system 2 thinking.  Knowing the textbook is not enough.  We need experience - thus the art.
==============

Robert M Centor, MD, MACP

Regional Dean, UAB Huntsville Regional Medical Campus
301 Governors Drive
Huntsville, AL 35801

Office: 256-539-7757
Fax: 256-551-4451

Chair, ACP Board of Regents

Professor, General Internal Medicine
UAB
FOT 720
1530 3rd Ave S
Birmingham, AL 35294-3407


From: Bob Latino <blatino at RELIABILITY.COM<mailto:blatino at RELIABILITY.COM>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Bob Latino <blatino at RELIABILITY.COM<mailto:blatino at RELIABILITY.COM>>
Date: Friday, January 9, 2015 at 1:51 PM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

I ask this as a non-clinician, "Should healthcare be more art than science?"

Understanding there are many unknowns in the field of medicine, as there are in science; but with regards to the 'knowns', shouldn't it be more science than art?

I come from the engineering disciplines (so from the left brain world), but with the 'knowns' there is a lot more structure and less variability in the application of the physical sciences in engineering.

With what is 'known' in medicine, why does there appear to be so much variability in 1) what is known (and who knows it) and 2) how it is effectively and consistently applied to the benefit of the patient.

Perhaps a naive question, but nonetheless on my mind as an layman observer:-)

Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.reliability.com&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=DXLacY0AzLQC9QIBcXYKUCxiHDXjqLlf_E7VbQzI8sU&e=>

From: David Lawrance [mailto:david.lawrance at gmail.com]
Sent: Friday, January 09, 2015 2:37 PM
To: Society to Improve Diagnosis in Medicine; Bob Latino
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

And, thank goodness, most people seem willing to pay us, again.

At this point it is generally protocol to mention that healthcare is more art than science. I think that is another way of saying that artists are more accident-prone than are scientists.

David

On Wed, Jan 7, 2015 at 6:43 AM, Bob Latino <blatino at reliability.com<mailto:blatino at reliability.com>> wrote:
We never seem to have the time and budget to do things right, but we always seem to have the time and budget to do them again!

Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645<tel:1.800.457.0645>
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.reliability.com&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=DXLacY0AzLQC9QIBcXYKUCxiHDXjqLlf_E7VbQzI8sU&e=>

From: Jason Maude [mailto:Jason.Maude at ISABELHEALTHCARE.COM<mailto:Jason.Maude at ISABELHEALTHCARE.COM>]
Sent: Wednesday, January 07, 2015 4:39 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

Thanks for alerting us to this article. One of the really positive things about the article is not just the improved care now being given but a great example of the Chief Medical Office and his senior colleagues managing/leading and setting a standard of care. He states in the article "I realize that many colleagues may see methods like ours as too intrusive on their clinical practice and may say that they don't have the time." I believe we need to see much more of this in hospitals. Too often, for example, we see DDS viewed as an end in itself rather than a tool to help with setting a standard of care and I think this explains why adoption of these tools is still relatively low.

Regards
Jason

Jason Maude
Founder and CEO Isabel Healthcare
Tel: +44 1428 644886<tel:%2B44%201428%20644886>
Tel: +1 703 879 1890<tel:%2B1%20703%20879%201890>
www.isabelhealthcare.com<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.isabelhealthcare.com_&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=tmxUA8BuP9Z9n9MUk8j2fGTa3AmaqNSxJOuyDvfX3Ps&e=>

From: <Bruno>, Michael <mbruno at HMC.PSU.EDU<mailto:mbruno at HMC.PSU.EDU>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, "Bruno, Michael" <mbruno at HMC.PSU.EDU<mailto:mbruno at HMC.PSU.EDU>>
Date: Tuesday, 6 January 2015 20:23
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

Greetings IMPROVEDX List-serve colleagues, and Happy New Year!

Thanks to Jason and Thomas for starting this years' discussion.

The attached article appeared in the Sunday New York Times.   I thought it was relevant to our group's discussion.

http://www.nytimes.com/2015/01/05/opinion/doctor-shut-up-and-listen.html?_r=0<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.nytimes.com_2015_01_05_opinion_doctor-2Dshut-2Dup-2Dand-2Dlisten.html-3F-5Fr-3D0&d=AwMFAw&c=6vgNTiRn9_pqCD9hKx9JgXN1VapJQ8JVoF8oWH1AgfQ&r=mY6wClgg9bB7_KFlGTqqsxa1oasn-a2wOpcZWTLBmj0&m=qffqJNXbGk1Y22GCt9UyBm2n32bIF4mnkdSNOw4yDnw&s=2uw5_WOXY2z3jGuLeqU94nbxI5Ghil9R6C2EkpAv5t8&e=>


All the best,

[Description: Description: Description: \\hersheymed.net\files\Staff\M\mbruno\Signature2.gif.gif]
Michael A. Bruno, M.D., F.A.C.R.
Professor of Radiology & Medicine
Director of Quality Services & Patient Safety
The Milton S. Hershey Medical Center
Penn State College of Medicine
500 University Drive, Mail Code H-066
Hershey, PA  17033

Phone: (717) 531-8703<tel:%28717%29%20531-8703>
Fax:      (717) 531-5596<tel:%28717%29%20531-5596>

e-mail: mbruno at hmc.psu.edu<mailto:mbruno at hmc.psu.edu>

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From: Carroll, Thomas [mailto:Thomas_Carroll at URMC.ROCHESTER.EDU]
Sent: Tuesday, January 06, 2015 1:44 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] "Early diagnostic suggestions improve accuracy of GPs"

Interesting.  My question would be how this would translate to the real world.  In this artificial environment we know whether or not the "correct" dx is in the list of suggested dx's.  That would not be the case in the real world.

Thomas M. Carroll M.D., Ph.D.
Assistant Professor, General Medicine & Palliative Care
University of Rochester
thomas_carroll at urmc.rochester.edu<mailto:thomas_carroll at urmc.rochester.edu>
Pager 5-1616 #3872
Tel: 585-275-7424<tel:585-275-7424> (General Medicine Office)
Tel: 585-273-1154<tel:585-273-1154> (Palliative Care Office)
Tel: 585-341-6775<tel:585-341-6775> (Resident Practice, Highland Hospital)

From: Jason Maude [mailto:Jason.Maude at ISABELHEALTHCARE.COM]
Sent: Tuesday, January 06, 2015 1:25 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] "Early diagnostic suggestions improve accuracy of GPs"

This is very interesting study just published in the British Journal of General Practice which also highlights the potential value of patients using symptom checkers and handing the results to their doctor at the start of the consultation. This would get over the current technical challenges of a system automatically producing a differential from more complex cases with multiple symptoms.

http://bjgp.org/content/65/630/e49<https://urldefense.proofpoint.com/v2/url?u=http-3A__bjgp.org_content_65_630_e49&d=AwMFAg&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=R16GG-MhGQFeEbiQbUUeP30HTmJHZlqL3XxjDPQtyXcSwB0zl0UIXhhofztdrEG1&m=eGvrWf26LmmmVkGW0vnRf9XeztEuR6JjBE8n1vgrIvU&s=uIrQIXl54eDZI6b32fN7ALZnLQKX_yTntnGzo_z3mD0&e=>

Regards and Happy New Year to the group.
Jason

Jason Maude
Founder and CEO Isabel Healthcare
Tel: +44 1428 644886<tel:%2B44%201428%20644886>
Tel: +1 703 879 1890<tel:%2B1%20703%20879%201890>
www.isabelhealthcare.com<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.isabelhealthcare.com_&d=AwMFAg&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=R16GG-MhGQFeEbiQbUUeP30HTmJHZlqL3XxjDPQtyXcSwB0zl0UIXhhofztdrEG1&m=eGvrWf26LmmmVkGW0vnRf9XeztEuR6JjBE8n1vgrIvU&s=rZEhyq7LgURp9ngavWrjRLodS2ccXYnsmuk6_HzmETc&e=>


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