Let me be clear: I hate that I type during my patient visits. But sometimes the computer adds value to the visit, allowing me to show patients their MRI findings, review guidelines with them, or find cheaper pharmacies for medications. Like with many tools, what matters is how you use it.
I work for instED out of Boston where paramedics go to patient's homes and then they call me for medical advice. I obviously can't make eye contact or touch the patient, but patients pay very close attention to what I say and how I say it. After over 50 years in medicine , I do know how to do this! I then complete the note in the computer after the visit based on memory.
I'm a little puzzled at the controversy. If you need to look at the screen or keyboard as you type then sure, you lose contact with the patient. But if you can touch type - and who can't touch type? - then your eyes are firmly on the patient as they speak and you type, and you make all the same expressions and ask all the same questions as if you weren't typing. In a nutshell, typing while the patient speaks changes very little if anything, and it makes for much better and accurate and more comprehensive notes.
Thank you Danielle! After reading Vinays OG post I just felt worse than usual. I try not to look at the screen when I type. Sometimes I notice the parent making eye contact with my student or resident shadowing and realize that I am looking at the screen too much. But, honestly, how perfect do you expect us to be? If I have to chart at night I never get to see my kids… let alone have a minute to myself. What gives?
It seems to me that this discussion will be anachronistic in 3....2....1. Artificial Intelligence, like it or not, is going to relieve doctors from this conundrum.
Wow, I feel lucky being a dinosaur. Before going into administration/government service I spent 23 years as a private practice family doc in a small town with a broad practice range. No EMR. I dictated my office notes, first with in house transcriptionist, then outsourced at 10 cents a line. I estimate 90% of my dictations were done in front of the patients. That allowed me to emphasize important points to the the patient "It is very important Mr. Smith keep his follow up appointment in 2 weeks." and it gave the patient the perception that I I spent more time with him/her. For some notes that were more sensitive, I would dictate between exam rooms. Went home to my children with no extra work to do, and had good, cogent, clinical notes.
I refuse to type my notes while visiting my patient. Truth be told I'm not a fan of EMRs period. Yes, my whole past was based on paper. I still like paper. I take short notes of my encounter with my patients. I spend my time looking around, watching, using all of my senses which paints a complete picture of my patient, not just the numbers, VS, etc. I add the little details of my visit after leaving their home. I write enough to see that visit in my mind as I enter my notes into the EMR at night.
Yes, I don't see as many patients per day as MDs. I also don't have 100s of patients to keep track of. I can't imagine how difficult that is for you.
The balance has come to me through the group I see now for well visits. My provider and I are completely focused on each other as my case manager types in notes, reconciles my medications, and double checks with my doctor as she ties up the notes and then they print them out for me.
Sadly this group has been mesmerized by the almighty dollar (IMHO) and has shortened the time my case manager spends in the exam room. She is moving on to the next pt already.
Who knows what my next MD visit will look like. A robotic voice coming over the intercom instructing me to take my own blood pressure (walks me through the procedure), asks me questions, and maybe, just maybe some day will verbally walk me through how to perform my own venipuncture using the correctly colored vials.
I am an academic - I do not see patients. I teach future medical practitioners and do research. Documentation is essential in any practice whether it be an ion-exchange column in the laboratory or seeing a patient with lower back pain. The point of this entire debate is how to balance proper documentation with compassionate and personal patient care. My own PCP, a chap who understands me well because we are both nerds, uses his computer extensively during my annual physicals because he must - no documentation, no remuneration. Having said that, he makes lots of eye contact, cracks plenty of bad “dad jokes,” and answers my questions as best he can. My urologist, who says he hates computers, uses a scribe, comes in humming the latest radio tune that’s on his mind, and finds humor in almost everything. Both medical professionals give me plenty of personal care and manage to document properly. Could it be that there is no “one size fits all” answer to this question. Vinay is probably blessed with a prodigious memory and can recall the details of each patient’s visit for mater documentation. Most of us are not as blessed as Vinay and may need the computer at the ready to document the data at hand. The point is being a patient-centered physician who plies their craft with compassion and competence.
Totally agree with this. I you're during my visit, but I can also tour without looking at the keyboard, allowing me to maintain eye cutest with the patient. I will often read back what I've written to the patient, and ask if they agree that I've heard them correctly. This reassures them that I am listening, and I care about getting their story down correctly
If you use a recording device/AI, what happens to the original and whose legal property is it? Seems there might be a bunch of issues if you have a written/edited report but the original pure visit exists in the cloud. Does an insurance company or lawyer have future access? Can the patient demand it be erased, or the doctor? Is it considered like the chart a medicolegal document that must be preserved?
It might be chilling to have an open conversation if everything you say to a doctor lives forever, just waiting for a subpoena or hacking. In my past job social workers became required to write their notes into the general electronic record. Quickly they developed "shadow charts" where they kept details the families wanted (or the social worker believed) needed to be truly private...
I strongly agree with Dr Howard that patients forgive and even appreciate the computer if you practice using it in ways that benefit them as well as you. I aim to divide my time on the computer between typing notes and showing them images, looking at lab and imaging reports together, and reading together my typed explanation of their symptoms or management options for clarity and accuracy. I have gotten positive feedback from patients on these practices and agree that at least for me, they best achieve the goals of completeness and accuracy of documentation, efficiency and transparency with patients. You’d be surprised how much people like seeing what you write about them and getting a chance to make suggestions and corrections!
I have no doubt that patients do care that I am burdened with crazy documentation requirements. BUT this is their appointment not mine. When I feel I need to write (type) something down during a visit, I will typically say something like “Excuse me but I really want to get this down correctly so I remember just how you described it” - this is honest, gives the patient the feeling that yes, I am listening, AND I get it right AND it’s down for me to fix (or not) later.
50 years ago my family’s orthopedic surgeon at the Joint and Bone Disease Hospital in NYC wore a recorder hanging from a strap and he engaged even with me a teenager with ski-damaged knees but dictated his notes. It was efficient and added to my and my family’s understanding.
And today with voice recognition the transcription would be near perfect. It wouldn't take too much time later to clean it up.
Unless you have 20 of them to clean up. Then that’s dinner with your family, time to exercise, or that extra hour of sleep you need to be present the next day.
My patients love that I roll up to them on my stool and look them in the eye and explain things or listen to them…many of them tell me I’m the only doctor they have that does this and does NOT type away on a computer or avoid eye contact. I see around 32 patients a day. I have my nurse print out my last note on the patient from the EMR, I quickly write some notes down on that from the computer about recent events or labs, then head into the room. I make some shorthand notes that I have developed over the years, and then use a medical dictation system with pre populated notes and add to that. I spend a lot of time with people, use my lunch hour to catch up, then finish about an hour behind by the end of the day. If I am too far behind, I will leave some of the notes and do them later. It’s about a 10 hour day without a minute break.
Perfect? No, but with a lot of extra effort I have been able to take good care of people and spend time with them, and earn the appreciation of my patients. It can be done….
I agree that my note is as much a communication tool to referring physicians as it is a reminder for myself of where we’ve been (wrt the pt’s case) and where I plan on going.
I’m also old school so I take the history, then dictate via voice recognition while the pt is changing in exam room, then examine (and similarly document), then dictate impression and plan after discussion with pt. So my note is done before next pt encounter. Doing notes at home after work is absolute non-starter.
Still, I think VP’s OP was a good reminder to pay attention to active listening and to be mindful of reducing intrusion of the EMR during pt encounter; but also accepting that some intrusion is a necessity.
That makes perfect sense. I think telling patients why you are typing away would be helpful. I love Dr. Cifu's intro--he's fine with a reader disagreeing with him but even better if it's one of his colleagues. I started reading Sensible Medicine because I went to school with Dr. Cifu but would probably never have come across it on my own. I'm so glad I did! sabrinalabow.substack.com
I am old enough to remember dictaphones, notes pasted into paper charts etc.
At current rates of technological progress, typing is headed the way of the dodo. Ambient AI populating notes is on the horizon. Already being used in some settings. ‘The future is here. It is just not evenly distributed’
it is not seamless as of yet and not generally widely available. It needs to be functioning within each physician's EHR and be able to formulate a note (generally in the format the particular physician would tend to use) AND place all the orders AND check any of the "quality" boxes that our system currently desires. "cut and paste" options are not truly efficient. It's definitely not placing orders as of yet. The "capture" and formulation still clunky.
But it is getting there. Just not clear to me how long this process will take. But if/when it happens, will be a paradigm shift.
It’s a fascinating evolution of technology capabilities. Used to be in-house scribes sitting somewhere near the medical records department. Those jobs then migrated to homes; probably the earliest version of remote/telecommute work. Then came the overseas medical transcriptionists. Of course, those jobs were again displaced by EHRs. It will be fascinating to see what type of work ambient AI displaces. Sooner or later, it will happen
I work for instED out of Boston where paramedics go to patient's homes and then they call me for medical advice. I obviously can't make eye contact or touch the patient, but patients pay very close attention to what I say and how I say it. After over 50 years in medicine , I do know how to do this! I then complete the note in the computer after the visit based on memory.
I'm a little puzzled at the controversy. If you need to look at the screen or keyboard as you type then sure, you lose contact with the patient. But if you can touch type - and who can't touch type? - then your eyes are firmly on the patient as they speak and you type, and you make all the same expressions and ask all the same questions as if you weren't typing. In a nutshell, typing while the patient speaks changes very little if anything, and it makes for much better and accurate and more comprehensive notes.
Thank you Danielle! After reading Vinays OG post I just felt worse than usual. I try not to look at the screen when I type. Sometimes I notice the parent making eye contact with my student or resident shadowing and realize that I am looking at the screen too much. But, honestly, how perfect do you expect us to be? If I have to chart at night I never get to see my kids… let alone have a minute to myself. What gives?
MANY THANKS for this rebuttal!
It seems to me that this discussion will be anachronistic in 3....2....1. Artificial Intelligence, like it or not, is going to relieve doctors from this conundrum.
Wow, I feel lucky being a dinosaur. Before going into administration/government service I spent 23 years as a private practice family doc in a small town with a broad practice range. No EMR. I dictated my office notes, first with in house transcriptionist, then outsourced at 10 cents a line. I estimate 90% of my dictations were done in front of the patients. That allowed me to emphasize important points to the the patient "It is very important Mr. Smith keep his follow up appointment in 2 weeks." and it gave the patient the perception that I I spent more time with him/her. For some notes that were more sensitive, I would dictate between exam rooms. Went home to my children with no extra work to do, and had good, cogent, clinical notes.
I refuse to type my notes while visiting my patient. Truth be told I'm not a fan of EMRs period. Yes, my whole past was based on paper. I still like paper. I take short notes of my encounter with my patients. I spend my time looking around, watching, using all of my senses which paints a complete picture of my patient, not just the numbers, VS, etc. I add the little details of my visit after leaving their home. I write enough to see that visit in my mind as I enter my notes into the EMR at night.
Yes, I don't see as many patients per day as MDs. I also don't have 100s of patients to keep track of. I can't imagine how difficult that is for you.
The balance has come to me through the group I see now for well visits. My provider and I are completely focused on each other as my case manager types in notes, reconciles my medications, and double checks with my doctor as she ties up the notes and then they print them out for me.
Sadly this group has been mesmerized by the almighty dollar (IMHO) and has shortened the time my case manager spends in the exam room. She is moving on to the next pt already.
Who knows what my next MD visit will look like. A robotic voice coming over the intercom instructing me to take my own blood pressure (walks me through the procedure), asks me questions, and maybe, just maybe some day will verbally walk me through how to perform my own venipuncture using the correctly colored vials.
I am an academic - I do not see patients. I teach future medical practitioners and do research. Documentation is essential in any practice whether it be an ion-exchange column in the laboratory or seeing a patient with lower back pain. The point of this entire debate is how to balance proper documentation with compassionate and personal patient care. My own PCP, a chap who understands me well because we are both nerds, uses his computer extensively during my annual physicals because he must - no documentation, no remuneration. Having said that, he makes lots of eye contact, cracks plenty of bad “dad jokes,” and answers my questions as best he can. My urologist, who says he hates computers, uses a scribe, comes in humming the latest radio tune that’s on his mind, and finds humor in almost everything. Both medical professionals give me plenty of personal care and manage to document properly. Could it be that there is no “one size fits all” answer to this question. Vinay is probably blessed with a prodigious memory and can recall the details of each patient’s visit for mater documentation. Most of us are not as blessed as Vinay and may need the computer at the ready to document the data at hand. The point is being a patient-centered physician who plies their craft with compassion and competence.
Totally agree with this. I you're during my visit, but I can also tour without looking at the keyboard, allowing me to maintain eye cutest with the patient. I will often read back what I've written to the patient, and ask if they agree that I've heard them correctly. This reassures them that I am listening, and I care about getting their story down correctly
If you use a recording device/AI, what happens to the original and whose legal property is it? Seems there might be a bunch of issues if you have a written/edited report but the original pure visit exists in the cloud. Does an insurance company or lawyer have future access? Can the patient demand it be erased, or the doctor? Is it considered like the chart a medicolegal document that must be preserved?
It might be chilling to have an open conversation if everything you say to a doctor lives forever, just waiting for a subpoena or hacking. In my past job social workers became required to write their notes into the general electronic record. Quickly they developed "shadow charts" where they kept details the families wanted (or the social worker believed) needed to be truly private...
I strongly agree with Dr Howard that patients forgive and even appreciate the computer if you practice using it in ways that benefit them as well as you. I aim to divide my time on the computer between typing notes and showing them images, looking at lab and imaging reports together, and reading together my typed explanation of their symptoms or management options for clarity and accuracy. I have gotten positive feedback from patients on these practices and agree that at least for me, they best achieve the goals of completeness and accuracy of documentation, efficiency and transparency with patients. You’d be surprised how much people like seeing what you write about them and getting a chance to make suggestions and corrections!
I have no doubt that patients do care that I am burdened with crazy documentation requirements. BUT this is their appointment not mine. When I feel I need to write (type) something down during a visit, I will typically say something like “Excuse me but I really want to get this down correctly so I remember just how you described it” - this is honest, gives the patient the feeling that yes, I am listening, AND I get it right AND it’s down for me to fix (or not) later.
50 years ago my family’s orthopedic surgeon at the Joint and Bone Disease Hospital in NYC wore a recorder hanging from a strap and he engaged even with me a teenager with ski-damaged knees but dictated his notes. It was efficient and added to my and my family’s understanding.
And today with voice recognition the transcription would be near perfect. It wouldn't take too much time later to clean it up.
Unless you have 20 of them to clean up. Then that’s dinner with your family, time to exercise, or that extra hour of sleep you need to be present the next day.
My patients love that I roll up to them on my stool and look them in the eye and explain things or listen to them…many of them tell me I’m the only doctor they have that does this and does NOT type away on a computer or avoid eye contact. I see around 32 patients a day. I have my nurse print out my last note on the patient from the EMR, I quickly write some notes down on that from the computer about recent events or labs, then head into the room. I make some shorthand notes that I have developed over the years, and then use a medical dictation system with pre populated notes and add to that. I spend a lot of time with people, use my lunch hour to catch up, then finish about an hour behind by the end of the day. If I am too far behind, I will leave some of the notes and do them later. It’s about a 10 hour day without a minute break.
Perfect? No, but with a lot of extra effort I have been able to take good care of people and spend time with them, and earn the appreciation of my patients. It can be done….
I agree that my note is as much a communication tool to referring physicians as it is a reminder for myself of where we’ve been (wrt the pt’s case) and where I plan on going.
I’m also old school so I take the history, then dictate via voice recognition while the pt is changing in exam room, then examine (and similarly document), then dictate impression and plan after discussion with pt. So my note is done before next pt encounter. Doing notes at home after work is absolute non-starter.
Still, I think VP’s OP was a good reminder to pay attention to active listening and to be mindful of reducing intrusion of the EMR during pt encounter; but also accepting that some intrusion is a necessity.
That makes perfect sense. I think telling patients why you are typing away would be helpful. I love Dr. Cifu's intro--he's fine with a reader disagreeing with him but even better if it's one of his colleagues. I started reading Sensible Medicine because I went to school with Dr. Cifu but would probably never have come across it on my own. I'm so glad I did! sabrinalabow.substack.com
I am old enough to remember dictaphones, notes pasted into paper charts etc.
At current rates of technological progress, typing is headed the way of the dodo. Ambient AI populating notes is on the horizon. Already being used in some settings. ‘The future is here. It is just not evenly distributed’
it is not seamless as of yet and not generally widely available. It needs to be functioning within each physician's EHR and be able to formulate a note (generally in the format the particular physician would tend to use) AND place all the orders AND check any of the "quality" boxes that our system currently desires. "cut and paste" options are not truly efficient. It's definitely not placing orders as of yet. The "capture" and formulation still clunky.
But it is getting there. Just not clear to me how long this process will take. But if/when it happens, will be a paradigm shift.
It’s a fascinating evolution of technology capabilities. Used to be in-house scribes sitting somewhere near the medical records department. Those jobs then migrated to homes; probably the earliest version of remote/telecommute work. Then came the overseas medical transcriptionists. Of course, those jobs were again displaced by EHRs. It will be fascinating to see what type of work ambient AI displaces. Sooner or later, it will happen
I remain hopeful that ambient AI will displace my second career as a medical transcriptionist and stenographer. Fingers crossed.