Skip to content Skip to navigation

Is Transcribing the Same as Listening?

June 6, 2009
by Jim Feldbaum, M.D.
| Reprints
Will the office EMR devalue the art of medicine?

My doctor must be listening; after all he is busy typing my answers to his questions into his laptop. Occasionally he lifts his head for clarification: “did you say it was your left or your right?” missing the subtlety that I am holding my injured arm protectively with my good arm.

As a consultant whose mission it is to convert physicians from the paper record to the EMR how should I respond to physicians who genuinely lament what they perceive as the devaluation of the skills of listening and observing in favor of documenting electronically? My generation of physician was trained to value a visit as an opportunity to go beyond the words spoken and to intuit the facts from the subtleties of expression, voice and body language. Further, they complain that documenting into the EMR makes the visit sterile inhibiting the environment of safety and trust so important to the doctor-patient interaction. Osler said that “listening is unspoken caring.” Do our patients feel cared for? Do they sense our compassion?

Rightly or wrongly, let’s assume that the new generations of physicians graduating from our medical schools have the skills to document while they listen, observe and instill trust. Furthermore, let’s assume that the new generation of patients have a matching set of expectations for their physician encounter. What about the rest of us?

For “older” physicians our relationships, both personal and professional, have never been “virtual.” Very few of us Twitter or text message. Even if we master the technical skills of data entry it still alters the way we relate to our patients during a visit. Our ingrained behavior, and for many our sense of satisfaction, demands an intensity of personal face to face interaction. We strive to key into the emotional and social stresses that make each patient unique. We can’t have one comforting hand on the patient and one on the keyboard. Demographically, most of our patient population too is of the “old school.” They expect to continue the style of relationship that they have become accustomed to with their physician, not just receive a diagnosis and treatment.

I can expound the benefits of the EMR, the PHR, evidence based medicine, clinical decision support and electronic prescribing. I can counter the complaints of cost and initial lost efficiency. The bigger question is how do I allay the fear, real or perceived, that a most cherished skill set and a style of relationship could be denigrated and potentially extinguished by adoption of the office EMR?

"To cure sometimes, to relieve often, to comfort always."

Anonymous

Topics

Comments

Jim,
Interesting post. I read it just weeks after reading David Allen's diatribe that we all fool ourselves believing that we can remember half of what we think we can. The solution is to write things down, considerably more exhaustively than we do now. That only applies to "stuff" we want to remember, not everything.

Your post brings up questions at the runway level (what to do in the exam room about note taking, handwritten or typed), as well as higher process issues (e.g. shouldn't the non-physician provider rooming the patient be accountable to capturing the nature of presenting illness, as well as key components like laterality? ... in addition to taking vitals, weight, meds validation, etc.)

When I was in practice, the term medication reconciliation was probably never used, despite the fact that the concept was understandable and of obvious benefit. Perhaps we should re-think encounter documentation to improve the ability of the provider to listen and raise the level of the art of medicine?  Per your post, the benefit seems pretty obvious as well.

In both professional writing and seeing patients, the write up needs to tell a clear story. Often, capturing details serially while spending time with a patient would result in something considerably less than a clear story. Most physicians I know capture a few notes in process. Then, with notes in front of them, dictate or write a comparatively brief note.

Exhaustive capture without post processing is generally bad on multiple counts.

Joe,
Looking back, I dictated each visit in folksy medical language in front of each patient. They always remarked that they couldn't believe that I remembered it all (in retrospect neither can I). Many remarked that they couldn't believe that someone actually listened (we have lowered patient expectations). Still, all I did was capture a narrative (albeit efficiently) and run up sizable transcription expenses. If only I could have captured some data in that environment.
As I was pondering this issue as a possible topic for the upcoming X3 summit it occurred to me that there may be a profound generation gap. I hate it when my son Max text messages in the middle of our conversations. He swears that he is listening, but it offends me. I consider it rude. The interesting flip side of this complaint is that probably Max can listen and text at the same time. Probably in his culture it is common and acceptable. His cohorts are not offended and they can transact their relationships normally. Should we design our systems for Max and his generation who are capable and accepting of electronic multi-tasking and who have different expectations and sensibilities. While they may be our future, demographically speaking, my generation can't yet be ignored.

I've been interviewing and typing for years, but I still do not have the skills to do BOTH at the same time, while truly listening and conducting a quality interview, especially when I'm dealing with a fast talker or someone with a thick accent. I prefer to stay in the moment with the source, truly listen in order to ask intelligent follow-up questions and see where the interview goes, rather than jerking the conversation back in line with one of my pre-written questions. To do that, I record the interview and transcribe it afterward.

It's very, very hard to do everything at once. I can imagine what it would be like for a physician to listen, engage with the patient and document at the same time.

James Feldbaum

Jim Feldbaum is a physician consultant specializing in clinical transformation, CPOE, and...