The Ephemeral Nature of Patient-Provider Consultations

October 29, 2009 at 10:23 pm 6 comments

I have seen many examples of ephemeral art: the chalk artist whose work will be washed away; the graffiti artist who uses mud instead of spray paint; and the Washington Monument’s face lift with specially designed scaffolding and draping. Ephemeral art is described as being transient and the fleeting, with no physical remnants (other than photographs).

A consultation has an ephemeral nature as well, with the physical remnants being doctor’s notes. Only rarely do patients have access to these, one exception being the OpenNotes© Project at Beth Israel Deaconess Medical Center which, according to a description, will “evaluate the impact on both patients and physicians of sharing the comments and observations made by physicians after each patient encounter.” Tom Delbanco, MD, anticipates this will improve patient recall and transform the doctor-patient relationship.

This may change what doctors write since they know that patients might read their notes. It may help patients with comprehension and recall, which have been shown to be reduced especially with a new diagnosis, and hopefully with adherence as well. There may be unanticipated results.

Certainly one of the most common ways to increase recall of a consultation is to increase the number of people there. I saw this first-hand as a patient advocate. Some of the responses, in comments and emails, to Why I Became Interested in Health Literacy, suggest ways of capturing a consultation with audio or video. There are clear advantages to this for patients who can then listen as many times as needed following the meeting, although the immediate opportunity to ask questions is lost. But, like a doctor who may write notes differently knowing they are available to the patient, a recording can change the nature of a consultation.

Knowing that OpenNotes© is new and that the other suggestions might be hard to implement, I asked some colleagues about their experiences with capturing what takes place during a consultation.

Some patients capture the instructions and the keywords. Tania Schlatter, a graphic designer, said her strategy is to “make them write it down for me. For example, my son has allergies and I made an appointment with the RN. She rattled off so much stuff I made her write it down for me. It was a messy scrawl on a bunch of stickies but that’s my reference now.”
 
Gilles Frydman, founder of ACOR.org, said that health literacy skills are no different in France than in the US but that “French doctors all the time record summaries of the conversations” for their patients. He went on to say, “They end up knowing the patients infinitely better than the average US doc using many times more technology. And the French patients are not more health literate than their US counterparts. Good health care is personal; technology should have enhanced that fact, not replaced it.”

Finally, I spoke to Paul S., who said, “The medical people I’ve worked with lately have been pretty good about writing down essential details such as over-the-counter drug names or suggested things to do or not do. Sometimes they have standard handouts that they print off on demand. That said, it would be really interesting to experience the OpenNotes process to compare what I think I got from the conversation with what the practitioner intended to convey. I don’t have the sense that I’ve missed anything from my consultations, but then that’s the point – I wouldn’t know! I have on occasion obtained a physician’s notes about tests or diagnoses, and have wished for someone to interpret the medical jargon. These are notes intended for other medical professionals, so the jargon is appropriate for that purpose. The interpretation of such notes for me might need to be, say, 3 times as many words because I know a fair bit about human biology, but it could easily be 10 or more times as many words for someone with less knowledge. And I know people for whom no amount of interpretation would be enough – they don’t want to understand anything, they just want the bottom line.”

My own recent experience with poison ivy (for the first time) was that my recall was not aided by husband, who had accompanied me to the nurse practitioner, but it helped me when I was frustrated. He repeated to me what she said: “It will get worse before it gets better” and “Nothing will make it go away faster, just reduce the symptoms.” His repetition helped me through a long two weeks.

It’s easy to reflect on the impact of changes: with the demise of Marcus Welby-like home visits, doctors could see more patients but could not see their home environments; and patients were in a much less comfortable environment, possibly impacting their health literacy skills due to the discomfort of being in a waiting room or being in an examining room in a paper gown. With all the technology available for every other aspect of our lives, and for healthcare in particular, there is no technological approach in practice that I know of that captures a consultation. It will be fascinating to see the results of OpenNotes© and mechanisms to give patients more access to health records. While ephemeral art changes the viewer’s reaction, knowing its transient nature, there seem to be few benefits to the ephemeral nature of consultations.

[Note: I just came across Amber J. Tresca’s Get the Most from Your Doctor’s Appointment, which recommends bringing paper to a doctor’s appointment to use for taking notes.]

Entry filed under: health. Tags: , , , .

Why I Became Interested in Health Literacy Improving Patient-Physician Communication about Internet Use: Why “Don’t Ask, Don’t Tell” Doesn’t Work

6 Comments Add your own

  • 1. Christine Kraft  |  January 13, 2010 at 3:26 am

    Wonderful post. I especially like your line, “A consultations has an ephemeral nature as well.” So true. And it is usually within that ephemera that a patient feels either well cared for and visible, or not so well cared for and … less visible. I would love to read more about that.

    Reply
  • 2. lodewijk bos  |  November 10, 2009 at 9:05 pm

    Lisa, great story. Since most practices have to start from scratch with this, why not try to combine the notes with Ix, to really advance the patient’s health literacy?

    Reply
  • 3. Paul S.  |  November 3, 2009 at 10:01 am

    Further thoughts:

    1. So much of current medical practice in the U.S. is driven by rewards and financial incentives. Physicians are paid based on number of patients seen, so their incentive is to spend minimal time with you or for you. Writing stuff down in a readable, legible, usable form takes more time.

    2. Physicians and even nurses are still trained to treat patients as children, so handing a child a pad to take notes doesn’t fit the model. We still have a long way to go in moving toward a model where patients bear responsibility for their own care, so that they are not only free to ask questions without feeling intimidated, but are actually encouraged to ask.

    3. There are now some companies building systems that make automated outward-bound telephone calls to remind people to make appointments, refill prescriptions, or take medications. I wonder how many of those calls could be omitted if only the patient got usable carry-home information at the time of the last consultation.

    Reply
  • 4. e-Patient Dave  |  November 2, 2009 at 6:35 am

    I guess once again I’m lucky to have Danny Sands as my MD. When I leave each visit I get a printout of his visit notes; he types them during the meeting, with me watching the monitor, and prints them as I leave. Why is this so difficult?

    Thinking about my other practitioners – hm, they don’t normally do that. I think I’m going to get insistent about it. Thanks.

    A side note – I had two specialist visits in September. For one I asked for a copy of his paper notes and the desk person actually laughed as she handed me an illegible sheet. It’s buried on my desk somewhere. For the other, I didn’t even think to ask. Boy, this stuff ain’t automatic!

    Reply
  • 5. Daniel Burnstein  |  November 1, 2009 at 1:12 am

    I think it helps me to have someone come with me to help me remember the comments/suggestions/Rx. I note that more and more docs are using written suggestions or my very advanced group practice, Harvard Vanguard in Boston uses a “summary of the visit’ notes – good to have and keep!

    Good article but a little swayed by the author’s own experiences perhaps.

    Zen distance is a good thing.

    Reply
  • 6. Tom Erickson  |  October 30, 2009 at 12:38 am

    I enjoyed your essay, Lisa. It provokes a couple of thoughts.

    One is that — in thinking back to the consultations I’ve had — I don’t believe I’ve ever been in a setting where I, as a patient, was provided with note-taking materials. A pencil and a pad of paper would not only acknowledge that human memory is not perfect, but would indicate that the consultation is providing important information, and that I should take some responsibility for following it. With the possible exception of needing to figure out how to prevent ill patients from transmitting their illness via shared writing materials, I can’t think of any drawbacks to this idea.

    Another is that though the OpenNotes solution is interesting, and it would be more so if is supported note-taking by both doctor and physician, and especially if it could support follow up questions and answers. I’ll bet I’m not the only who gets home and then — in the context where I need to take the medication or change the bandage or decide if a new symptom is worrisome — suddenly realize that I should have asked some other questions. But I — and I think most people — are not very good at projecting projecting ourselves into other contexts. Wouldn’t it be nice if I could get back to my OpenNotes record, and post a question. And, ideally, OpenNotes would notify the physician, and make sure that various cues (physicians have imperfect memories too) — my records, my picture, the date of my visit — were available along with the notes. That would turn OpenNotes into OpenTalk, which would suit my needs a lot more.

    Reply

Leave a Reply

Please log in using one of these methods to post your comment:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

Trackback this post  |  Subscribe to the comments via RSS Feed


Lisa Gualtieri, PhD, ScM

Lisa GualtieriLisa Gualtieri is Assistant Professor at Tufts University School of Medicine in the Department of Public Health and Community Medicine. She is Director of the Certificate Program in Digital Health Communication. Lisa teaches Designing Health Campaigns using Social Media, Social Media and Health, Mobile Health Design, and Digital Strategies for Health Communication. Contact Lisa: lisa.gualtieri@tufts.edu

@lisagualtieri


%d bloggers like this: