When the patient is in the room, stop typing your note

A simple lesson for doctors

Recently a friend of mine joined his relative at the oncologist’s office. His relative was being treated for an aggressive malignancy. My friend’s job was to serve as eyes and ears and he was supposed to ask questions his loved one might forget.

The doctor, a cancer specialist, walked in. Introductions were made. The doctor tapped her badge to log into EPIC. Then, she turned, half facing the computer, but half facing the patient and began typing. How were you doing? Is your pain better or worse? On a scale of 1 to 10…? After every question, she typed briskly, while asking another. Would you say your nausea has improved? Click click click.

My friend could not shake the feeling that the doctor’s attention wasn’t fully there. She seemed more preoccupied with writing down useless information. “So did you feel weakest 2 days or 3 days after chemotherapy?” (PS — why would that matter?) As a result, she wasn’t fully present. She wasn’t listening, and responding, the way you would a loved one or friend. That was my friend’s perception. I suspect he is right.

We have to do better in health care.

I have been writing notes on patients for 17 years now. In the early years, they were by hand, and now they are on the computer. I write them before I see the patient, and finalize them just after. I only write them in the physician team room— not the exam room.

My notes are short and to the point. I refuse to input any auto-text. If I didn’t do it (a physical exam maneuver), I don’t document it. Sadly, in my experience, 90% of physicians notes contain lies. Exams they didn’t perform, or medications they didn’t confirm.

When I am in the room with the patient, I usually sit on the stool and talk. I only turn the computer on, when the patent asks me something and I have to look it up. For instance, if they say, what are my platelets today. I say, they are up into the 150s. Then they say, but what exactly. I say, hold on, let me check. Log in, and check. 154.

Sometimes, if I didn’t do it beforehand, and if the patient is going there immediately after seeing me, I will order labs while in the room. I do this only after the talking is over, and I do this, so when they go to lab, there is no wait.

When I give lectures to students, I am often trying to make a big point, and they keep typing away in their laptops the minutiae of what I am saying. I am tempted to say. “Stop typing. Listen to what I am saying. Take away the big picture. Nothing I am saying needs to be written down. I am not giving you a list of facts, but trying to make an argument. You don’t need to document the details. Plus I can give you a copy of my slides, etc later.”

Why do doctors write the note while with the patient? Because they want to be efficient. There is no time later. They have to go their daughter’s softball game when clinic ends.

Frankly, I know what it is like to be overwhelmed. I get more emails a week than I could ever answer in a month. But, I am not sympathetic to these excuses.

See fewer patients.

That’s the solution. If your clinic is so busy you can’t be present, see fewer patients. Open another day of clinic. Or, refer to a colleague.

No one doctor can see every patient. It is better to see fewer patients and do the job well. Be the doctor you would want for yourself.

My position in medicine is clear. Dress professionally. Show up on time. Don’t call in fake sick. If the hospitalized patient asks for water, go get it. If you are talking to someone who is dying, be present. And, if the administrators are putting so much pressure on you that you feel you can’t do this— the bare minimum— then tell them to go to hell.