Turn of the computer and pay attention to the patient!!!

HM Epstein hmepstein at GMAIL.COM
Sat Oct 1 16:17:26 UTC 2016


Thanks, Lisa. That's an excellent approach; it turns the conversation from a confrontation (why are you doing X?) to a dialogue (I feel Y when X happens).  

You and I communicate for a living so it's obvious to us that lack of eye contact is damaging to doctor-patient relations. I also wonder if her 30 years of experience was upended when her practice introduced EHRs. 

Best,
Helene 

-- 
hmepstein.com 
@hmepstein
Mobile: 914-522-2116

Sent from my iPhone



On Oct 1, 2016, at 7:26 AM, Sanders, Lisa <lisa.sanders at yale.edu> wrote:

I wonder if simply telling the doctor that you feel unheard and unattended when she focuses so completely on her computer would be helpful. I know it seems obvious to you that this behavior on her part would be upsetting to the patient but she may not know.
 
Lisa
 
From: HM Epstein [mailto:hmepstein at GMAIL.COM] 
Sent: Friday, September 30, 2016 11:52 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Turn of the computer and pay attention to the patient!!!
 
Thanks Tom:
 
I will try to be gentle. IF she is still hyper-focused on her laptop and not engaging perhaps I will start with asking her how she is doing and is everything alright. I try never to assume that I can read someone's motivation or emotional state until there's a conversation. Perhaps my being kind will make her kinder and more attentive. 
 
And of course I have biases. My biases are many:
I expect a doctor to be knowledgeable. 
I expect my doctor to care about keeping me healthy or at least to care if I am suffering (I'm not suffering but that's a low bar)
I expect a dialogue the very first time I meet a doctor. Questions are great. Listening to the answers even better.
I expect a thorough physical exam before I get a diagnosis and treatment plan. A question about what I do for a living might be appropriate since it might be a cause for my symptoms. 
I expect the same thing from her as I do from every human I meet in a one-on-one encounter. Eye contact and a handshake or greeting at the start or the end. Basically an acknowledgment that I'm a human too.
I hope for a physician who won't dismiss my answers while I'm in mid-sentence. I'm concise and I always have a plan for what I'm going to say so the most important questions or data are mentioned first.
Finally, I expect my doctor to respect that I'm an expert about the patient sitting in her exam room. If s/he wants to figure out the cause of my symptoms, I hope s/he will grill the expert witness.
I'm the daughter and sister of doctors so I know they don't have full control of their environment of care. I know most physicians working in a group practice or aligned with a larger hospital group may have little to say about how they're reimbursed or incentivised, what days or hours they work. I know they can't do all of the tests they may want to do, or might be pushed to use certain profit centers that aren't always necessary. I recognize that all physicians are people with needs and responsibilities. I do hope though that they still put the patient's life or death healthcare needs ahead of their reimbursement structure. I expect the same thing of the structural engineer who built my apartment building and any other expert who holds my safety and life in their hands. When I'm in the exam room with a health issue, I shouldn't have to care about how my doctor gets paid or whether their EHR is difficult for them to understand or whether they are seeing too many patients. I DO care but I shouldn't have to.
 
By the way, I recommend physician Anne Lippin's blog, especially this post "Laying down my stethoscope." http://annelippin.com/blog/2016/08/08/laying-down-my-stethoscope/
 
Best,
Helene

hmepstein.com
@hmepstein
Mobile: 914-522-2116
 
On Fri, Sep 30, 2016 at 9:18 AM, Tom Benzoni <benzonit at gmail.com> wrote:
I do think that gentle questioning and seeing the landscape she is seeing will be very revealing.

It will, among other things, reveal your own likely innate biases; we all have them.

For instance, you likely believe she controls her environment of care, like I believe you control which word processing program you use. Is that true?

Such an exploration will be very revealing, surprising and pleasant.

The unpleasant part will be the result of seeing your own biases...

That's a topic for another day.

tom

 
On Sep 29, 2016 10:13 PM, "HM Epstein" <hmepstein at gmail.com> wrote:
Thank you Tom. I looked up WOMBAT and first I learned it was "one of the strangest looking creatures I ever will see." And then I added the letters BMC and I found what I suspected. Work Observation Method By Activity 
Timing. Are you suggesting I tell her that I am doing a wombat on her? Oh my. That would be interesting. Hahah. 
 
Best,
Helene
-- 
hmepstein.com 
@hmepstein
Mobile: 914-522-2116
 
Sent from my iPhone
 
 

On Sep 29, 2016, at 11:01 PM, Tom Benzoni <benzonit at gmail.com> wrote:

Perhaps a gently asked question as to why so much time is spent staring at the screen, followed by a WOMBAT (search WOMBAT, BMC,) may produce some interesting data. And sympathy in place of attribution bias.
 
On Thu, Sep 29, 2016 at 9:19 PM, HM Epstein <hmepstein at gmail.com> wrote:
Thank you Liz. I agree the process was a waste of her time. And mine. Perhaps they were shortstaffed that day. Perhaps she was just having a bad day. 
 
Luckily I have time to work on how to word the request. Hopefully she won't keep her nose in the laptop and I won't have to say a word. 
 
It's fascinating and disheartening to watch all the things I write about come alive right in front of me. 
 
Best,
Helene 

On Sep 29, 2016, at 5:45 PM, Regan, Elizabeth <ReganE at NJHealth.org> wrote:

Dear Helen,
What a disheartening story!
For myself, I can’t imagine that the process you describe allows her to integrate the information and do the complex analysis that one should expect from a physician.  She was functioning as a scribe.  What a criminal waste of a physician education!  Maybe it was just to get the prescription properly recorded with diagnoses and pharmacy information. I still think that this could be work done by a nurse or medical assistant rather than the physician.
 
I will be very interested to hear how your next visit goes.  It is possible that she will accomplish the right tasks but …
I think that I would favor a direct request to her to talk with you and not focus on the computer.  I think it is somewhat likely that it will elicit anger but you may as well learn that earlier than later.
 
Good luck,
Liz
 
From: HM Epstein <hmepstein at GMAIL.COM>
Reply-To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, HM Epstein <hmepstein at GMAIL.COM>
Date: Wednesday, September 28, 2016 at 9:48 PM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Turn of the computer and pay attention to the patient!!!
 
"The history." I love that answer!
 
Here's a recent story from a patient point of view. I moved back to NYC last year. I booked an annual checkup with a highly recommended internist who mishandled my history, cut me off when I attempted to answer her questions, rejected my description of an injury to my elbow, and so on. She determined I had a cardio issue (I didn't), had strained my elbow (I tore a tendon), misdiagnosed the cause of numbness in one limb (it turned out to be a spinal issue), refused my request for a GI referral for some serious and worsening symptoms and instead chose to handle it herself, ordering meds without ordering any tests. Of course this led to a horrendous six months of pain and delayed Dx and treatment. I found my own specialists and recently moved my care to a new PCP. 
 
So, I met the new PCP this week. She was a referral from one of my specialists who said she was a great diagnostician. Luckily, this wasn't my annual check up. It was just an initial first meeting to get a couple of prescriptions refilled while I wait for my annual check up next month. 
 
She spent the whole appointment with her face in her laptop. I came in prepared with my most recent blood test and a printout of my prescriptions, and I had had reports sent in in advance from the G.I., the cardiologist, and the orthopedist. She hadn't read anything. She asked me questions as they appeared on her screen, she recorded my answers, she didn't interrupt and I thought she listened to me, but she didn't retain a single answer or any aspect of the narrative so she asked me the same questions over and over. 
 
When I come back next month for my annual check up, knowing that she now has my whole history on her computer, I plan to ask her to close the lid and talk to me first. 
 
So, for the experts on this listserv, what can I say to her that will motivate her to look up and engage without turning her off?
 
Thank you for any advice or direction.
 
Best,
Helene
 
-- 

hmepstein.com 
@hmepstein
Mobile: 914-522-2116
 
Sent from my iPhone
 

 


On Sep 28, 2016, at 5:26 PM, . <0000000697ec7b18-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG> wrote:

When I talked to groups of physicians about making the proper Dx in spinal pain patients, someone often would ask "What is the one best Dx study to do if you could only do one?"  My answer - "The History."
PHil Benton, MD, JD
Atlanta

Phillip Benton
pgbentonmd at aol.com
 

-----Original Message-----
From: Bruno, Michael <mbruno at HMC.PSU.EDU>
To: IMPROVEDX <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Sent: Mon, Sep 26, 2016 8:01 pm
Subject: [IMPROVEDX] Turn of the computer and pay attention to the patient!!!

See the attachment – I think this is an excellent article, echoing several threads discussed in this group over the past couple of years.
 
All the best,
 
<image001.png>
Michael A. Bruno, M.D., F.A.C.R.
Professor of Radiology & Medicine
Vice Chair for Quality and Patient Safety
Chief, Division of Emergency Radiology
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
Fax:      (717) 531-5737

e-mail: mbruno at hmc.psu.edu
 
 
<image002.png>

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