Making Sense of Medicine: Bridging the Gap Between Doctor Guidelines and Patient Preferences
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Open notes, on my own

10/28/2014

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My practice at Johns Hopkins has many virtues, but we have not yet adopted open notes. Through EPIC's MyChart system, patients can have access to their lab results and communicate directly with their doctors. (That is, the 25% of patients who sign up; patients who are too poor or disadvantaged to have computer access or facility are shut out from the beginning.) But we don't let anyone see their doctors' notes.

I won't revisit here the recent Open Notes trial which has found a surprising willingness from doctors to continue after a year of tryouts. I want to talk about my own limited, small-scale experience.

We don't have Open Notes as a clinic, but I'm trying it out by myself. I type as I see the patient, and let them know that at checkout, when the patient instructions are printed out, the note (as drafted, with all the mistakes and typos included) will be printed out for them too.

Some observations have come to mind over the past month as I've pursued my little non-experiment.

1. Patients seem to appreciate it.
2. I have received a handful (perhaps half a dozen or so) corrections out of a hundred or so notes. Perhaps patients are not used to correcting, or don't feel they have "permission."
3. I think more often about the register of language I use. I'm nervous about abandoning medical lingo, but think I should certainly tailor my presentation to the patient, if they are seeing the note.
4. I think I might be more careful in how I speak about the patient, knowing they might read the note.

What are your thoughts about this open notes trial of mine?

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Knifedancing

10/22/2014

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This week, I covered for one of the chief residents. I was the attending physician for about 25 patients in the hospital during the space of a few days. On one of those days, I still had scheduled my regular outpatient clinic; the entire day became a way to experience the contradictions inherent in the practice of medicine, crossing the street again and again between the hospital and my clinic like a shuttle on a loom.

How many contradictions, or rather, pairings that we see as contradictions, confronted me with each patient I saw, comparing in my mind the medicine I practice every day in clinic with the kind of health care delivered in our hospitals!
  • Providing each person the care that works for her uniquely, while uniformly assuring best practices for safety to hundreds of patients at a time.
  • Getting the tests and treatments that are needed as fast as possible, while deliberating appropriately on the evidence base of every intervention.
  • Treating pain -- but acknowledging the dangers of opiate addiction.
  • Enabling the patient to make decisions, while recognizing they need the support of a treatment team in an alienating and scary environment.
  • Discharging as soon as medically possible, while aiding the patient in their convalescence.
  • Hewing to principles of safety and organizational efficiency, while being unafraid to venture out of the box when changed situations demand it.
How can we treat patients while on the very knife-edge of these contradictions? Treating both inpatients and outpatients makes me more sensitive to the edge, but I’m not sure I can dance any better….yet.
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Patient-centered communication: a useful clinical review

10/1/2014

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The 5 E's: ethics, efficiency, effectiveness, equity, and emotions: how does patient-centered communication relate?
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    The author of Talking To Your Doctor and Making Sense of Medicine blogs about the books, shared decision making, doctor-patient communication, and the redeemable imperfections of healthcare.

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