I recently discovered that one of the great storytellers of our day – Malcolm Gladwell has a new podcast – Revisionist History. Each episode (he is now into Season 2) takes a look at some piece of history and through some delightful storytelling revisits the history and our perceptions of events. It reminded me of this piece I wrote some time back focused on the importance of storytelling in and the history we capture from our patients.
The Patient Story
Stories are the backbone of who we are. They provide context, insight, subtle and not-so-subtle hints about ourselves and those around us. They teach us lessons and help us determine similarities and differences so that we can avoid mistakes and replicate success.
Much like Malcolm Gladwell’s new podcast, the popular Serial podcast is dedicated to deeply exploring different narratives, stories, and evidence, in order to find insight into a mystery. I found it fascinating for myriad reasons, but mostly for the way it was told. And, at the beginning of each episode is the reminder: “This is Serial: one story told week by week.”
It’s engaging and thought-provoking, but what I like most is that it forces the listener to consider the same principle case from different perspectives. I was struck by how similar this journalistic process of poring over reports and talking with people to hear their perspectives is to the art of medicine. When a patient comes to see you with a set of symptoms, you have your checklist: you examine him, you ask questions, maybe order lab tests.
If your patient’s condition persists, you might talk to his son, who brought him into the follow-up appointment, and he might mention something his father had forgotten or dismissed as irrelevant. You carefully listen to what is said, and what is not said, noting anything that is out of the ordinary. You use that patient’s chart as your journalist’s notepad.
The Luxury of Time
The difference is that physicians don’t always have the luxury of time. Whether it’s because treatment decisions need to be made or there is a line of patients waiting to be seen, they need to have quick access to the most relevant data and best practices so they can make informed decisions and recommendations to their patients. They need to be able to collaborate with a specialist to look at a medical image and report together, discussing whether that secondary finding is something more than it appears.
Compounding matters are that as the healthcare industry awkwardly shifts to value-based care, physicians have been forced to precariously straddle the line between two oppositional models, and amidst it all, they try desperately to not let the tumult affect their patients. They’re beholden to the regulatory bodies that govern how they practice and they have sworn an oath to protect and care for those who have entrusted them with one of their most valuable gifts: their health.
As Drs. Patrick Ober and William Applegate so eloquently as succinctly articulated in their recent article “The electronic health record: Are we the tools of our tools?”:
“Attentiveness to the nuances of communication is an essential attribute of a skilled physician; in its quest for medical standardization, the EHR discourages nuances and promotes functional medical illiteracy.”
Time Pressure is Killing the Story
Physicians are being forced to make hard choices, and one of these sacrifices often comes at the expense of the patient story. And when you lose that story, the patient becomes a collection of somewhat unconnected data points. This has a profound downstream impact as the next attending physician will have to go through the same rigorous exercise of asking questions and sleuthing around, which not only frustrates the patient, it can lead to unnecessary wasted time.
The overall health IT endgame is the right one: creating a continuous and integrated care cycle that helps drive the best care outcomes. While technology is a key component in the healthcare ecosystem, it should only play a supporting role. It helps sifts through the massive amounts of data and appeases the regulatory requirements so that the physician can listen attentively to his patient as she walks him through the series of changes and symptoms she has experienced.
In healthcare, the story is everything. Nothing happens in a vacuum. As physicians, it is our responsibility to listen to our patients and their family members, noting the details, and helping them understand and treat their symptoms. We can’t do this if we’re not paying attention.
Capturing the Story
It’s not a lack of willingness on the part of the healthcare professionals but rather the time pressures of other tasks that have precluded the capture of the story. What small improvements could we make in the system to increase the time for patients to share their story?
- Maximizing the time with the clinician requires we ease the burden of administrative tasks from the clinical team
- Identify any tasks that can be carried out by others – simple administrative functions that could be assigned to other members of the team
- Patient engagement can occur long before the face to face visit with their clinicians and allow patients access to their records and the ability to validate and update their information
- Move the healthcare payment model to value-based care and drop the requirement of documentation for the purposes of billing would change the focus of the consultation to be clinical, not financial
This is an important area for clinicians – we recognize the value of the history and to this day the history still contributes some 80% to the diagnosis of a patient’s condition. This alone should provide the impetus to change the system to allow the patient story to be front and center.
Do you have any better suggestions? What small change have you seen that makes a difference in the use of Telehealth services. What one thing could we do that would have a big impact in this area?
This piece originally appeared on HITConusltant
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