“It’s odd about these three things” my 58 year old patient said. Only half listening as I search the EHR for care I mumble yes, it is a little odd. Changing his clothes on the other side of the curtain he had repeated that it seemed funny he’d had three separate things go wrong lately. Today diarrhea, last week a superficial thrombophlebitis, and, still getting my electronic bearings, I had not caught the third. “Tell me again.”
“I think I wrenched myself while reaching over to lift a heavy bag of groceries. I feel fine now, but a few nights ago it was hard to sleep.” I pull the curtain, push my laptop to the side and look him in the eye. He points to his left lateral chest wall, demonstrating the offending twisting motion. Finally present, I ask: Have you had any shortness of breath? No. Hemoptysis? No. How is your leg doing? Much improved. Any chest symptoms now? No, completely resolved.
It may be nothing more than a pulled muscle, but I am worried. Last week I had been unsettled by his superficial thrombosis. Why this in a healthy middle aged man with no weight loss or other constitutional signs and who is up to date on his cancer screening. My concern rose to high alert. Despite the superficial location of his recent thrombophlebitis, could this be a pulmonary embolus?
Instead of sending him on his way after a reassuring exam, as I had been intending, I send him to the lab. An hour later his d-dimer returns greater than 5000. Two hours later his CT angiogram reveals a sub-segmental pulmonary embolism with infarct. Reviewing the films with the radiologist I am humbled and aghast. I came close to missing this. If not for the pause.
“Sam, it was really important you told me about what seemed like just a pulled muscle. The tests we ran this afternoon show that you have a blood clot in the lung.” Alarm crosses his face. “We will treat that. But Sam I need to tell you about something else. I just studied your films with the radiologist. We see some spots in your liver…” He squeezes his eyes shut in recoil against my words. “Oh no”. His voice and body begin to shake. His wife hadn’t come with him today. He is alone. “I’d like to do a few more tests to understand what is going on.”
It is 5:00 pm on Friday and he is overwhelmed. We need to teach him about self-administered heparin, do more blood work and order the abdominal CT scan. He can’t process any of this. My nurse joins us, calm, caring. I tell him we are his team, and we will go through this together. She has already ordered the enoxaparin and will give him his first injection. She stays until after six, working with the receptionist to get the CT scheduled, and because he doesn’t feel he can give himself the injections, she arranges for the urgent care center to give the shots over the weekend. We have a tough road ahead. Together.
It bothers me how close I was to not doubling back to ask about the third symptom--how easily I could have missed his clue. He presented with a new, pedestrian complaint—diarrhea, but hidden within was more. I believe I would have missed the diagnosis if he had not helped me, by returning to what seemed odd to him after I’d missed it the first time. It was only in pausing to be fully present that I finally heard him.
How much do I miss when multi-tasking, my own hard drive spinning with all of the technical details of the electronic data interface: remember to double click the first time you do a dictation, but only single click and then drag the bar when adding an addendum, otherwise you will erase your earlier dictation. Twenty one clicks and 5 screen changes to complete the billing invoice. Don’t forget to add a “P” for primary in front of one of the diagnoses and don’t include more than 4 diagnoses.....
My initial reaction to my near miss is humility and dismay. Inward emotions focused on my personal failures. Why can’t I do all of this? Other physicians seem to have accommodated a remarkable volume of clerical tasks without buckling. What is wrong with me?
But on reflection I am also angry. Angry at what has been made of my profession, at what is lost for both patients and physicians, as we become data entry clerks and billing secretaries.
Frantic multi-tasking during an appointment is now the norm, pulling the doctor’s attention away from the patient, as it did in my care of Mr. Kline. Studies in our practice reveal it takes an average of 3 seconds of physician time to schedule future appointments, lab and x-ray using a paper order set, and 2 minutes to do this same work through computerized order entry. It takes 23 seconds to enter a family history on paper and 2 min and 14 seconds to enter that same information in structured text. This time adds up and can quickly consume much of the 15 minute visit. I have shadowed primary care physicians across the country, and have observed this same pressure in almost every setting. The physician is typing during the majority of the encounter, giving only partial attention to the patient.
The pressure against the pause, the lack of time to push back and observe just a little more, the inattentiveness to subtle signals from the patient—this is an environment driving trainees and practicing physicians away from primary care and, sometimes, sending patients on unnecessary, expensive expeditions through the healthcare system.
What is missed when we lose moments for unhurried listening: “Tell me about yourself” “How was your trip here?” Even as a good typist, when my fingers are flitting across the keyboard or my eyes are focused on finding the elusive ICD-9 diagnosis for billing, I am not able to fully listen. Yet moments of concentrated listening can, I believe, lead to more accurate decision making, more patient engagement, less costly care, and can ultimately be healing for both the patient and the physician as we find the focus to say to our patients “tell me again, let me make sure I’ve understood you.” If not for the pause we risk missing the present.
- Levinson W, Pizzo PA . Patient-Physican Communication: It's About Time JAMA. 2011;305(17):1802-1803
- Chesluk BJ, Holmboe ES. How Teams Work—Or Don’t—In Primary Care: A Field Study On Internal Medicine Practices. doi: 10.1377/hlthaff.2009.1093 HEALTH AFFAIRS 29, NO. 5 (2010): 874–879
originally published in the Society of General Internal Medicine Forum 2013; 36(5)