4 ms·

The doctors individually spending 5 quiet minutes reviewing the case files of the patients they were about to treat BEFORE they arrived. That's not modern real

The doctors individually spending 5 quiet minutes reviewing the case files of the patients they were about to treat BEFORE they arrived. That's not modern reality and its shameful.

araes 9y ago
This was the desired behavior. Its not that they reviewed existing info to check for changes, its that they knew nothing. Like the last 30 minutes of questions and chart didn't exist. On the side of the patient, this does not inspire confidence. It projects a sense of confusion and disorganization.
- kbenson 9y ago
  Twenty years ago when I did tech support for a living, I had a series of questions worded in very specific ways I would ask at the start of a call. Sometimes the content of the answer was the useful part of the response, sometimes how the answer was said. More often than not, if I got someone on the other line that seemed to know a bit, skipping the questions ended up being counterproductive, as I would assume some knowledge about a specific item from the other end that didn't exist (but other knowledge did). I learned to trust the process, and glean the extra bits of information that weren't what the other side was trying to convey, but did nonetheless. I think it's a mistake to assume that just because the doctor asks you questions and doesn't always seem to take into account a prior answer the doctor is not listing. I think it's more likely that they have learned that the small percentage of time that asking similar questions in different ways has led to new, important information has led them to be careful and methodical, even at the expense of patients thinking they aren't listening. When faced with a choice of behaving in a way making you think they care, or behaving in a way that makes you think they don't but actually provides better care and outcomes, what would you prefer? I think we need to be careful about jumping from "this is what it looks like" to "this is what's going on" without evidence clearly pointing to one over that other.
  - civilitty 9y ago
    > When faced with a choice of behaving in a way making you think they care, or behaving in a way that makes you think they don't but actually provides better care and outcomes, what would you prefer? I think we need to be careful about jumping from "this is what it looks like" to "this is what's going on" without evidence clearly pointing to one over that other. This is an important point but I feel you're approaching it from a very short term view. Look at Pakistan, for example: after the CIA used a vaccination program as cover for a genetic testing scheme meant to find Bin Laden [1], there was (and still is) a significant impact on the Pakistani and other population's trust in their domestic healthcare industry [2]. Even if it was a real Polio vaccination program that saved thousands of lives in a purely utilitarian short term calculation, the damage that distrust causes long term can far outweigh the benefits. Worst of all, due to the nature of that distrust, measuring that damage becomes so much harder. The point is, doctors don't just need their patients to trust them, but to trust the institution of modern medicine and healthcare as a whole. They need the patients to trust their nurses, pharmacists, specialists, and technicians just as much as the primary doctor. Given how critical patient cooperation/honesty and preventative care are to clinical outcomes, I don't see any convincing evidence that patient perception isn't just as important as the rest of the process. [1] https://www.theguardian.com/world/2011/jul/11/cia-fake-vaccinations-osama-bin-ladens-dna https://www.theguardian.com/world/2011/jul/11/cia-fake-vacci... [2] https://www.scientificamerican.com/article/how-cia-fake-vaccination-campaign-endangers-us-all/ https://www.scientificamerican.com/article/how-cia-fake-vacc...
  - araes 9y ago
    His very countenance rippled like the sea, and the sound of my own voice came back to me, distorted. ... it was how I affected his sounds and how she affected mine that transmitted the message. - SMAC I don't disagree with what I interpret as the intent of your message - that there is real value in process, question repetition, and not jumping to conclusions. I do think it implies a false choice at the end though. A doctor can imply they care / listen / are familiar with your case, while still asking insightful questions and probing for relevant changes. [Analogy] As there are many engineers here, consider this contracting example: how would most companies respond if, for a project, at each meeting, the contractor sent a new representative, who asked all the same questions as the first meeting, could provide no status updates, and many reps suggested apparently different solutions, platforms, or approaches?
- mikecsh 9y ago
  > its that they knew nothing That does sound rather concerning if that's the case! As a medical student about to sit my final exams, I have shadowed hundreds of doctors of different grades and specialties in many different hospitals and family practices, and I don't recall ever seeing a doctor not review the notes before seeing a patient. Often here in the UK at least there is a large amount of time pressure and it would certainly be desirable to have more time to review further back, in more detail, etc. but given in general practice there is a 10 minute slot per patient, there are systemic limits on this (that would be nice to address). On the other side, trying to figure out what is going on with patients is much more complex than catching up on notes and trying to get a "delta" update from them about what has changed in the shortest space of time/words as possible. The number of times I have taken a history from a patient and then less than half an hour later observed them add hugely important extra details that were omitted previously is pretty large. Often, it is far more helpful and illuminating to ask a patient to tell you what has been going on in their own words, even if you think you have read it all in the notes. I have often seen more senior clinicians pick up subtle clues that were missed by more junior clinicians, or ask a pertinent question that was not asked before. And finally, on a more pragmatic basis, doctors take a lot of risk on board whenever they treat a patient. Patient's get tired of people asking them if they have any allergies for example, but when it's your name on the prescription, and your ability to sleep and your license on the line, you may well decide to ask the patient again rather than rely on what some previous clinician in some previous setting has written down on the patient's file. In a similar vein, a lot of practice is not black and white. If a junior with limited experience writes that a particular clinical sign is positive in the notes, you may well want to repeat that examination to re-assure yourself before you allow it to guide your treatment. None of this is excusing unpreparedness or poor practice, but hopefully shines a little light on some reasons why it seems like there is so much needless repetition.
  - araes 9y ago
    You bring up good points and your last is particularly relevant in this case, as the patient arrived with what were termed simple problems, was expelled due to lack of finances, died suddenly a week later apparently due to MRSA contracted at the care facility, and the family is now considering malpractice. Your name on the line is a very real risk. Unfortunately, I expect this may create a lawyer averse culture where process is as repeatable as possible, because in the event of a suit, systematic process is a solid defense.
- Floegipoky 9y ago
  To play devil's advocate, patient handoffs are incredibly risky and one of the biggest causes of medical error. Retaking patient history is one of the best ways to reduce that risk. Think of it like talking to a project's stakeholders yourself rather than relying on requirements gathered by somebody else.
waffle_ss 9y ago
That's not modern reality according to whom? My spouse is an MD and she spends a minimum of 45 minutes before her shift reviewing her patients' charts. After work, at home she tidies up patient notes to ensure the next person gets an efficient summary of the patient. Then after dinner she's answering a bunch of instant messages from patients on the hospital's patient portal and doing any prep necessary for the next day. Programmers would be collectively rending our garments if we had to do anywhere near the amount of unpaid / off-the-clock work as doctors do.
- YeGoblynQueenne 9y ago
  On the other hand, at least some of us would give an arm or a leg to be able to do work as impactful and useful as doctors.
milesdyson_phd 9y ago
5 minutes lol. From a surgery perspective: Getting a consult as an intern on a patient with a big case file is like (at least) 30 minutes of reading notes, then you talk with the patient, then you talk with your senior, then you and the senior go talk to the patient, then the senior talks to the attending (depending). Sign out (patient hand off) can take a while depending on the size of the list but I don't know any other interns that don't stalk the charts before they are about to come in so it's usually just a quick brief on each patient and what therapies are going on. Did I mention you do sign out (on trauma) after having been at the hospital for 24+ (sometimes 30 depending on attending) hours? Things can and do still get missed.

The doctors individually spending 5 quiet minutes reviewing the case files of the patients they were about to treat BEFORE they arrived. That's not modern reality and its shameful.

araes 9y ago

This was the desired behavior. Its not that they reviewed existing info to check for changes, its that they knew nothing. Like the last 30 minutes of questions and chart didn't exist. On the side of the patient, this does not inspire confidence. It projects a sense of confusion and disorganization.

kbenson 9y ago
Twenty years ago when I did tech support for a living, I had a series of questions worded in very specific ways I would ask at the start of a call. Sometimes the content of the answer was the useful part of the response, sometimes how the answer was said. More often than not, if I got someone on the other line that seemed to know a bit, skipping the questions ended up being counterproductive, as I would assume some knowledge about a specific item from the other end that didn't exist (but other knowledge did). I learned to trust the process, and glean the extra bits of information that weren't what the other side was trying to convey, but did nonetheless. I think it's a mistake to assume that just because the doctor asks you questions and doesn't always seem to take into account a prior answer the doctor is not listing. I think it's more likely that they have learned that the small percentage of time that asking similar questions in different ways has led to new, important information has led them to be careful and methodical, even at the expense of patients thinking they aren't listening. When faced with a choice of behaving in a way making you think they care, or behaving in a way that makes you think they don't but actually provides better care and outcomes, what would you prefer? I think we need to be careful about jumping from "this is what it looks like" to "this is what's going on" without evidence clearly pointing to one over that other.
- civilitty 9y ago
  > When faced with a choice of behaving in a way making you think they care, or behaving in a way that makes you think they don't but actually provides better care and outcomes, what would you prefer? I think we need to be careful about jumping from "this is what it looks like" to "this is what's going on" without evidence clearly pointing to one over that other. This is an important point but I feel you're approaching it from a very short term view. Look at Pakistan, for example: after the CIA used a vaccination program as cover for a genetic testing scheme meant to find Bin Laden [1], there was (and still is) a significant impact on the Pakistani and other population's trust in their domestic healthcare industry [2]. Even if it was a real Polio vaccination program that saved thousands of lives in a purely utilitarian short term calculation, the damage that distrust causes long term can far outweigh the benefits. Worst of all, due to the nature of that distrust, measuring that damage becomes so much harder. The point is, doctors don't just need their patients to trust them, but to trust the institution of modern medicine and healthcare as a whole. They need the patients to trust their nurses, pharmacists, specialists, and technicians just as much as the primary doctor. Given how critical patient cooperation/honesty and preventative care are to clinical outcomes, I don't see any convincing evidence that patient perception isn't just as important as the rest of the process. [1] https://www.theguardian.com/world/2011/jul/11/cia-fake-vaccinations-osama-bin-ladens-dna https://www.theguardian.com/world/2011/jul/11/cia-fake-vacci... [2] https://www.scientificamerican.com/article/how-cia-fake-vaccination-campaign-endangers-us-all/ https://www.scientificamerican.com/article/how-cia-fake-vacc...
- araes 9y ago
  His very countenance rippled like the sea, and the sound of my own voice came back to me, distorted. ... it was how I affected his sounds and how she affected mine that transmitted the message. - SMAC I don't disagree with what I interpret as the intent of your message - that there is real value in process, question repetition, and not jumping to conclusions. I do think it implies a false choice at the end though. A doctor can imply they care / listen / are familiar with your case, while still asking insightful questions and probing for relevant changes. [Analogy] As there are many engineers here, consider this contracting example: how would most companies respond if, for a project, at each meeting, the contractor sent a new representative, who asked all the same questions as the first meeting, could provide no status updates, and many reps suggested apparently different solutions, platforms, or approaches?
mikecsh 9y ago
> its that they knew nothing That does sound rather concerning if that's the case! As a medical student about to sit my final exams, I have shadowed hundreds of doctors of different grades and specialties in many different hospitals and family practices, and I don't recall ever seeing a doctor not review the notes before seeing a patient. Often here in the UK at least there is a large amount of time pressure and it would certainly be desirable to have more time to review further back, in more detail, etc. but given in general practice there is a 10 minute slot per patient, there are systemic limits on this (that would be nice to address). On the other side, trying to figure out what is going on with patients is much more complex than catching up on notes and trying to get a "delta" update from them about what has changed in the shortest space of time/words as possible. The number of times I have taken a history from a patient and then less than half an hour later observed them add hugely important extra details that were omitted previously is pretty large. Often, it is far more helpful and illuminating to ask a patient to tell you what has been going on in their own words, even if you think you have read it all in the notes. I have often seen more senior clinicians pick up subtle clues that were missed by more junior clinicians, or ask a pertinent question that was not asked before. And finally, on a more pragmatic basis, doctors take a lot of risk on board whenever they treat a patient. Patient's get tired of people asking them if they have any allergies for example, but when it's your name on the prescription, and your ability to sleep and your license on the line, you may well decide to ask the patient again rather than rely on what some previous clinician in some previous setting has written down on the patient's file. In a similar vein, a lot of practice is not black and white. If a junior with limited experience writes that a particular clinical sign is positive in the notes, you may well want to repeat that examination to re-assure yourself before you allow it to guide your treatment. None of this is excusing unpreparedness or poor practice, but hopefully shines a little light on some reasons why it seems like there is so much needless repetition.
- araes 9y ago
  You bring up good points and your last is particularly relevant in this case, as the patient arrived with what were termed simple problems, was expelled due to lack of finances, died suddenly a week later apparently due to MRSA contracted at the care facility, and the family is now considering malpractice. Your name on the line is a very real risk. Unfortunately, I expect this may create a lawyer averse culture where process is as repeatable as possible, because in the event of a suit, systematic process is a solid defense.
Floegipoky 9y ago
To play devil's advocate, patient handoffs are incredibly risky and one of the biggest causes of medical error. Retaking patient history is one of the best ways to reduce that risk. Think of it like talking to a project's stakeholders yourself rather than relying on requirements gathered by somebody else.

waffle_ss 9y ago

That's not modern reality according to whom? My spouse is an MD and she spends a minimum of 45 minutes before her shift reviewing her patients' charts. After work, at home she tidies up patient notes to ensure the next person gets an efficient summary of the patient. Then after dinner she's answering a bunch of instant messages from patients on the hospital's patient portal and doing any prep necessary for the next day. Programmers would be collectively rending our garments if we had to do anywhere near the amount of unpaid / off-the-clock work as doctors do.

YeGoblynQueenne 9y ago
On the other hand, at least some of us would give an arm or a leg to be able to do work as impactful and useful as doctors.

milesdyson_phd 9y ago

5 minutes lol. From a surgery perspective: Getting a consult as an intern on a patient with a big case file is like (at least) 30 minutes of reading notes, then you talk with the patient, then you talk with your senior, then you and the senior go talk to the patient, then the senior talks to the attending (depending). Sign out (patient hand off) can take a while depending on the size of the list but I don't know any other interns that don't stalk the charts before they are about to come in so it's usually just a quick brief on each patient and what therapies are going on. Did I mention you do sign out (on trauma) after having been at the hospital for 24+ (sometimes 30 depending on attending) hours? Things can and do still get missed.