D.I.Y. doctoring

It’s far too early to begin a comprehensive list of the lessons to be learned from the ongoing Ebola situation. Each day brings a new revelation of another misstep or oversight that this frighteningly virulent virus has taken as an opportunity to spread its lethality. However, at the very beginning of the unfortunate debacle in Dallas, the question of who knew what and when became a focus. It is interesting, and not surprising, that the hospital where the index case presented was quick to blame a failure of its electronic health record (EHR) to allow various members of its health team to share information about the patient’s history.

Within days, the hospital retracted this explanation. But, the fact that EHRs were the first scapegoat demonstrates how dissatisfied and distrustful the medical profession is of computerized medical records. Many of us who practice medicine at the first interface with patients feel that we have been sold a bill of goods by the software vendors. Or, at the very least, we see ourselves as lab rats in a nationwide experiment in health information management, a beta-test that is not going well.

One revelation from the Dallas hospital was that the intake nurse took a history to which the doctor had access, but that the doctor took his or her own history during the 10-minute visit. If we ever hear more about the details of this unfortunate clinical encounter, we may discover that it was simply a case of physician seeing the dots but failing to make the correct connections. However, I am going to seize the opportunity to question a situation in health care delivery that troubles me.

If you have ever been a patient anywhere in this country in the last 20 years, you know to expect that you will be asked scores of questions by several people with varying amounts of training and experience. Your interrogation may begin with a clipboard you are handed in the waiting room. It will likely continue with an assistant – someone in a costume that suggests some medical training. Many of the questions will be repeated and repeated and seldom will be used to initiate a dialogue.

If you are lucky, the next person you see will be the “provider,” who may or may not look at the clipboard or computer screen. He or she may ask you some of the same questions again and, if you are very lucky, your answers may result in a conversation during which the provider will learn more about you and what is troubling you. If you are very unlucky, you may be referred to another provider or testing facility where this scenario will be repeated again.

Some of the questions provide necessary demographic information; others are intended to create a distant past history (such as how old you were when your parents misguidedly sent you to have your tonsils and adenoids out) that is unlikely to be of much clinical significance. I accept that this minutiae that has little clinical value is best collected by someone other than the provider. But, I submit that the patient’s chief complaint and the review of systems need only be gathered by one person, the provider. For most simple encounters, certainly those involving pediatric patients and most folks under the age of 50 years, the patient’s description of the present illness should unfold as part of a conversation during which the provider learns more about the patient and why he or she is sitting there in the office.

The notion that having an assistant obtain an extensive review of systems and history of the present illness saves the provider time is flawed. If it does save any time, it is often at the expense of not offering the provider a rich, full-color picture of the patient. Many patients complain that it appears the provider hasn’t read the answers to the questions that they have been asked several times. In cases in which the provider has taken the time to look at the answers, he or she may appear to have “always had his nose in the computer and never looked me in the eye.”

It’s time to reinject a little bit of D.I.Y. (do it yourself) doctoring into our practices. We may never know, but it may be that if one physician in Dallas had been solely responsible for obtaining the patient’s history and review of systems, disaster may have been averted.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected].

It’s far too early to begin a comprehensive list of the lessons to be learned from the ongoing Ebola situation. Each day brings a new revelation of another misstep or oversight that this frighteningly virulent virus has taken as an opportunity to spread its lethality. However, at the very beginning of the unfortunate debacle in Dallas, the question of who knew what and when became a focus. It is interesting, and not surprising, that the hospital where the index case presented was quick to blame a failure of its electronic health record (EHR) to allow various members of its health team to share information about the patient’s history.

Within days, the hospital retracted this explanation. But, the fact that EHRs were the first scapegoat demonstrates how dissatisfied and distrustful the medical profession is of computerized medical records. Many of us who practice medicine at the first interface with patients feel that we have been sold a bill of goods by the software vendors. Or, at the very least, we see ourselves as lab rats in a nationwide experiment in health information management, a beta-test that is not going well.

One revelation from the Dallas hospital was that the intake nurse took a history to which the doctor had access, but that the doctor took his or her own history during the 10-minute visit. If we ever hear more about the details of this unfortunate clinical encounter, we may discover that it was simply a case of physician seeing the dots but failing to make the correct connections. However, I am going to seize the opportunity to question a situation in health care delivery that troubles me.

If you have ever been a patient anywhere in this country in the last 20 years, you know to expect that you will be asked scores of questions by several people with varying amounts of training and experience. Your interrogation may begin with a clipboard you are handed in the waiting room. It will likely continue with an assistant – someone in a costume that suggests some medical training. Many of the questions will be repeated and repeated and seldom will be used to initiate a dialogue.

If you are lucky, the next person you see will be the “provider,” who may or may not look at the clipboard or computer screen. He or she may ask you some of the same questions again and, if you are very lucky, your answers may result in a conversation during which the provider will learn more about you and what is troubling you. If you are very unlucky, you may be referred to another provider or testing facility where this scenario will be repeated again.

Some of the questions provide necessary demographic information; others are intended to create a distant past history (such as how old you were when your parents misguidedly sent you to have your tonsils and adenoids out) that is unlikely to be of much clinical significance. I accept that this minutiae that has little clinical value is best collected by someone other than the provider. But, I submit that the patient’s chief complaint and the review of systems need only be gathered by one person, the provider. For most simple encounters, certainly those involving pediatric patients and most folks under the age of 50 years, the patient’s description of the present illness should unfold as part of a conversation during which the provider learns more about the patient and why he or she is sitting there in the office.

The notion that having an assistant obtain an extensive review of systems and history of the present illness saves the provider time is flawed. If it does save any time, it is often at the expense of not offering the provider a rich, full-color picture of the patient. Many patients complain that it appears the provider hasn’t read the answers to the questions that they have been asked several times. In cases in which the provider has taken the time to look at the answers, he or she may appear to have “always had his nose in the computer and never looked me in the eye.”

It’s time to reinject a little bit of D.I.Y. (do it yourself) doctoring into our practices. We may never know, but it may be that if one physician in Dallas had been solely responsible for obtaining the patient’s history and review of systems, disaster may have been averted.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected].

It’s far too early to begin a comprehensive list of the lessons to be learned from the ongoing Ebola situation. Each day brings a new revelation of another misstep or oversight that this frighteningly virulent virus has taken as an opportunity to spread its lethality. However, at the very beginning of the unfortunate debacle in Dallas, the question of who knew what and when became a focus. It is interesting, and not surprising, that the hospital where the index case presented was quick to blame a failure of its electronic health record (EHR) to allow various members of its health team to share information about the patient’s history.

Within days, the hospital retracted this explanation. But, the fact that EHRs were the first scapegoat demonstrates how dissatisfied and distrustful the medical profession is of computerized medical records. Many of us who practice medicine at the first interface with patients feel that we have been sold a bill of goods by the software vendors. Or, at the very least, we see ourselves as lab rats in a nationwide experiment in health information management, a beta-test that is not going well.

One revelation from the Dallas hospital was that the intake nurse took a history to which the doctor had access, but that the doctor took his or her own history during the 10-minute visit. If we ever hear more about the details of this unfortunate clinical encounter, we may discover that it was simply a case of physician seeing the dots but failing to make the correct connections. However, I am going to seize the opportunity to question a situation in health care delivery that troubles me.

If you have ever been a patient anywhere in this country in the last 20 years, you know to expect that you will be asked scores of questions by several people with varying amounts of training and experience. Your interrogation may begin with a clipboard you are handed in the waiting room. It will likely continue with an assistant – someone in a costume that suggests some medical training. Many of the questions will be repeated and repeated and seldom will be used to initiate a dialogue.

If you are lucky, the next person you see will be the “provider,” who may or may not look at the clipboard or computer screen. He or she may ask you some of the same questions again and, if you are very lucky, your answers may result in a conversation during which the provider will learn more about you and what is troubling you. If you are very unlucky, you may be referred to another provider or testing facility where this scenario will be repeated again.

Some of the questions provide necessary demographic information; others are intended to create a distant past history (such as how old you were when your parents misguidedly sent you to have your tonsils and adenoids out) that is unlikely to be of much clinical significance. I accept that this minutiae that has little clinical value is best collected by someone other than the provider. But, I submit that the patient’s chief complaint and the review of systems need only be gathered by one person, the provider. For most simple encounters, certainly those involving pediatric patients and most folks under the age of 50 years, the patient’s description of the present illness should unfold as part of a conversation during which the provider learns more about the patient and why he or she is sitting there in the office.

The notion that having an assistant obtain an extensive review of systems and history of the present illness saves the provider time is flawed. If it does save any time, it is often at the expense of not offering the provider a rich, full-color picture of the patient. Many patients complain that it appears the provider hasn’t read the answers to the questions that they have been asked several times. In cases in which the provider has taken the time to look at the answers, he or she may appear to have “always had his nose in the computer and never looked me in the eye.”

It’s time to reinject a little bit of D.I.Y. (do it yourself) doctoring into our practices. We may never know, but it may be that if one physician in Dallas had been solely responsible for obtaining the patient’s history and review of systems, disaster may have been averted.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected].