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The Monster in the Exam Room

His name was Dr. Frank. He made house calls to my family when I was growing up in New Jersey. He carried a black bag, which was more symbolic than practical because he had few medications. His style of medicine would be considered bizarre by today’s standards.

Most of us can recall the idyllic scenario of the kindly family doc who knew us, our family, and provided peace and comfort during difficult times. Often in our homes. Payment was in cash. I do not recall any medical records or insurance forms.

But let’s look at the delivery of care now and what we need to know to take full advantage of our engagement with today’s healthcare system where there are no Dr. Franks.

Hello, Electronic Monster

The federal government has mandated the electronic health record for all large medical organizations. This was an overwhelming task because of the crushing volume of medical information on each patient. Mountains of paper files, notes, X-rays, lab results, reports. And much of the information is maintained in physical files by various medical offices and hospitals.

Imagine trying to bring some coherence to complex software packages used for revenue cycles, reimbursement, billing, and related financial activities. Tracking for prescriptions written by several different doctors. Then embed a clinical system of medical records, so we now have a profoundly inefficient electronic mishmash that’s mercilessly difficult to master and the source of great frustration for your providers—and for you.

Think about your last clinical visit. Did the doctor hunch over a computer and keyboard or a handheld iPad in the exam room? Fire off questions from the screens? Type away instead of examining you? Has the electronic monster become yet another visitor with you in the exam room?

The Harm of Distraction

In some studies more than half of a physician’s day is spent on the computer rather than with patient care. So what does this mean for all of us, as patients?

Psychologists and efficiency experts who have studied medical practices conclude that this digital monster poses a conundrum of interruptions and distractions, which clearly impacts patient care and safety.

Let’s suppose your doctor is engaged in task A, which might be reviewing a ton of emails or text messages. These are profoundly disruptive, rarely affirming, and are usually a demand or some expectation. Now the doc toggles to task B such as seeing a patient, performing a physical examination, and outlining a plan of tests and images.

Studies show that task A is still on the doctor’s mind even as the doc addresses task B. This is called attention residue.

In other words, the pressure of time compromises your doctor’s cognitive power. Cognitive processing power (paying attention to you as you sit in a paper gown on a cold chair and talk about your aches and pains and concerns) becomes diminished and performances deteriorate.

The less time that we allocate between switching tasks A and B creates more anxiety, and the quality of decisions goes down as does time to recall events and circumstances. We as patients need to understand and be mindful that the provider is being bombarded with intrusions (task A still on the doctor’s mind, a nurse asking about another patient, an urgent phone call about a critical patient in the ER, a text from a spouse about a family event, a colleague’s need to discuss a puzzling patient, tapping and clicking away on that digital beast in the exam room to record every answer and note, and on and on).

"Now where was I?"

“Now where was I?” Oh, yes, back to you, the patient, sitting in the paper gown. If you sense your doctor is distracted, you can respectfully ask for a reclarification or rephrasing of an important medical issue. Just as we as consumers of healthcare sense that the provider is distracted—and not on top of his or her game—we certainly have the right to ask for clarification of a previous conversation. After all, no one has a greater stake in your health and well-being than you.

We have all had the experience of being immersed in a challenge such as making a cake or tackling some financial issue, when the text message tone dings, or the doorbell rings, you’re pulled away, and then later you say to yourself, “Now where was I?”

We as providers whether physicians or nurses or physician assistants need to be mindful of this attention residue phenomenon. To open up Facebook, plow through a ton of emails, and then switch to that patient in front of us is not an ideal transition. We need to slow down and recognize that task switching can be disastrous.

The Human Petri Dish

In some medical centers like the Mayo Clinic where I work, clinicians work in a common work space where there are computer monitors, keyboards, and related devices. It is a fertile area for the sharing of information and management but is also a human petri dish for interruptions and distractions.

A colleague sitting next to me had opened a patient’s chart and was ready to go into the exam room. But there was a ding of notification of an email. Rather than ignore the email, he opened it and the news was not good. A grant funding his research was rejected and the consequences were significant. He was deflated, crestfallen.

And then he had to face a patient and family with a serious problem. Without doubt, he was distracted and unfocused. And that patient and family undoubtedly did not have his undivided attention.

With the universal application of the electronic health record, every aspect of the provider’s day can be measured, calculated, and compared with other practitioners. Every keyboard stroke, every click of the mouse can be quantitative, and that clinician’s performance can be compared to a peer group. These metrics of performance and productivity can be intimidating, highly misleading, and a source of distraction for the provider.

Let’s say Dr. Smith, a family practitioner, carefully evaluates the patient and requests a surgical consultation. Let’s say that the consultation was electronically entered at 9:00 a.m. The surgeon is delayed and does not evaluate the patient until 11:00 a.m. that same day. In the audit of electronic records, the family practitioner was criticized for having kept the patient waiting for two hours. But she had no control over that situation.

If a patient is elderly, ill, and requires more assistance to be weighed and to address business issues before going in the exam room, an audit of that physician’s records might suggest that he was not efficient in expediting that patient’s evaluation. The providers also can be criticized for length of notes, the number of times laboratory data were reviewed in the room, and other time-sensitive issues.

These are anxiety-provoking circumstances and certainly are a factor in provider distractions, which can clearly impact upon patient satisfaction and patient care.

As a patient, do this:

  • If the doctor seems rushed and not attentive, say this: “You seem to be in a hurry. Would it be better for me to return another day when you are not so distracted?”

  • If the doctor makes recommendations, repeat the plan and have the doctor reaffirm: You say, “So I’ll have an X-ray and then you’ll call me later today to see if I need a CT scan? What time will I hear from you?” Write down the instructions just so you know the plan.

  • Understand what the doctor says in terms you can understand.

Here’s a real-life situation: I was visiting a family member who was in a double occupancy room at a metropolitan hospital. My family member was in the bed by the window. A thin curtain separated him from an elderly gentleman who was in the bed by the door.

A physician came into the room and this is exactly what I overheard, “We think you had a PE, but we need to do a Doppler of your legs, and to be certain we better throw in an echo, and once we get that back, we can put our heads together.”

As a medical professional I obviously knew what he meant, but the patient had a glazed look and was completely clueless. The patient should say this: “I don’t understand what you are telling me. What are these tests? Can you explain in terms I know?”

The physician should have said: “We are concerned that your shortness of breath may reflect a blood clot, which can travel into your lungs. The blood clot usually starts in veins of the legs, so we better do a test with a small device about the size of a tube of toothpaste. We gently rub this over your legs, and we can detect any evidence of a blood clot. This is not a big deal. Sometimes a blood clot can start in the heart, so let’s take a picture of your heart with the same kind of device, which is gently rubbed over the chest wall. Again, this is not a big deal. Once we have that information back, we can sit down with the family and map out what this all means and where we go from here. Is there anything that I did not explain?”

  • If the doctor is spending too much time on the screen and not looking at you, say this: “I will appreciate your attention to me and not the medical record. I know you have to record this, but I am right here in front of you. Please talk to me directly.”

  • Understand how to access the electronic patient portal. Almost every healthcare system will provide you with a user name and password to actually read and see what the provider has entered in your medical record. This type of access gives you some insight into the decision-making process, what recommendations were shared, and the results of laboratory studies and imaging such as X-rays and CT scans. Before you leave the doctor’s office, say this: “Do you have an online patient portal and how do I get access to my medical records?”

Let the medical system tackle the intricacies of the electronic medical record, which has enormous efficiencies, but do not let the electronic monster detract from your face time with your clinicians either. Smart patients can navigate the digital doctor distractions.

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