by Abraham Verghese, MD
This month I am the attending physician overseeing an internal medicine team, one of four such teams that admit patients to my teaching hospital. It’s a great time to be an attending physician. I have seasoned interns who in just a few weeks will be junior residents, and I have even more seasoned senior residents on their way to entering practice or entering subspecialty training. The team feels very efficient.
What always strikes me when I come back to being on the in-patient wards is the mountain of data that exists on each patient. It’s a surprise every time, a feeling analogous to revisiting Bombay or Madras after years of being away and finding that a city you did not think could get more congested, has done just that.
For example, if we admit to our service a patient who once had a transplant in our hospital, that guarantees records from many prior admissions–a veritable encyclopedia in the computer. Add to that everything generated in the hours that they were in the emergency room before making their way up to the ward (ER attending’s note, blood tests, imaging studies, nurses’ notes, consultants’ notes) and you find that the real patient under the sheets is dwarfed by the labels and data that precede them. The task of sifting through that pile of information seems to get more challenging every year.
A few days ago my brother sent me a paper quoting the psychologist Herbert Simon who in 1969 lecture said:
“the wealth of information means a dearth of something else: a scarcity of whatever it is that information consumes. What information consumes is rather obvious: it consumes the attention of its recipients. Hence a wealth of information creates a poverty of attention and a need to allocate that attention efficiently among the overabundance of information sources that might consume it.”
Simon anticipated by 40 years the issue I’ve been wrestling with this week: is the information extant per patient, the sheer mass of it (measured not in stacks of papers, but in searchable gigabytes) at times detrimental to patient care? Data = mass = gravitational pull so that any of us opening a patient file enters a force field and find ourselves sucked in. For the interns’ generation which has grown up on computers, the force is perhaps stronger or the nature of that kind of work is familiar.
Being a good doctor does involve carefully studying the old records. In the old days, one had to make an effort to go to the file room and get the dusty old charts, or if they were not there, track them to the cubbyhole where they awaited someone’s signature. There was virtue in the effort simply because less conscientious physicians might not bother and they therefore might duplicate tests that needn’t be done, or might miss the boat altogether in terms of what ailed the patient.
Nowadays, as I watch us all scour the digital records (no dust to inhale, no rubber bands that snap in your face) the task is so much easier. The new issue is that the information can detract and distract; we can wind up sitting too long in the chair staring at it. To paraphrase T.S. Eliot, knowledge can get lost in information, just as wisdom can get lost in knowledge.
On several occasions this week, I’ve felt that my time at our patients’ bedsides, examining them (because only the exam can tell you if there is pain and if it’s better than yesterday, and they seem more or less anxious today), learning who exactly they are, getting to understand what they want and most importantly listening to what they can tell us about their body, has helped make sense of confusing test results and contradictory stories piling up in the computer (and they pile up thanks to the cut-and-paste function which perpetuates misinformation).
So, in response to my brilliant student who is performing at the very highest level but who asked me this morning how he might get even better on the wards, I quoted Herbert Adam’s words –poverty of attention– which is going to be my new mantra, and I unveiled my Special Theory of Attentivity:
a = Ac + Ap
Where a is the total attention we give to a patient’s problem, Ac is minutes we spend attending to the computer while Ap is minutes at the patient’s bedside.
I suggested to him that Ac and Ap should at least be equal; preferably we should err to much more of Ap–time at the bedside. I suggested that he try to meet the patient in the flesh first before he shook hands with the patient’s data; I suggested he work on getting as much as he can from listening to the patient, from sounding the body and only then turn to the computer. It’s the opposite of how we now do things. I told him he might be humbled by what the records will show him he has missed, and he might be proud of what he has found that is not in the record or is wrong in the record.
I hope he’ll find that his interaction with the patient will feel different, truly new because he will approach them without bias or labels.
Let’s see what he reports. I have no doubt we will both learn something.
Abraham Verghese is Professor and Senior Associate Chair for the Theory and Practice of Medicine at Stanford University School of Medicine. He is the author of Cutting for Stone and blogs at The Atlantic, where this article was originally published. It is re-posted here with the author’s permission.
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Thank you Dr. Verghese for so clearly elucidating a problem that many of us face today and putting forth an excellent way to deal with it. As we train our junior colleagues it is also important to train our patients as well not to blindly trust the computer system as well. I have always tried to meet the patient before their chart so as not to be biased by the data/notes of those before me but have been shocked by the patients reply to “why are you here?” or “what can I do for you?” with “Haven’t you read my chart?”
Another common answer I get is “it’s in the computer I’m sure” when asking about their medications or past medical history. I still go through the data with them, just to show them how many things are inaccurate. “I never had my gallbladder out.” “Well, I was given that medication, but I never started taking it.” As Dr. Verghese pointed out, the patient can teach us much more than a computer screen.
Many in-patients are cared for by hospitalists who then hand these patients back to their primary physicians. Tons of data are generated after a few days of hospitalization. Will all of the hospital test results, consultant recommendations, abnormal labs and x-ray abnormalities be communicated to the primary physician whose responsbility it will be to address all of the medical loose ends, many of which are not related to the illness at hand? This is an enormous challenge and I wonder how well we ar meeting it.
Since patients have such a wonderful way of forgetting important things like “Oh yeah, I did have a liver transplant,” I like to print out a recent discharge summary or H&P and take it into the patient’s room with me. I read through and confirm a few key points – “So is this true? and this?” – and then conduct the rest of the H&P like usual.
Where is the Life we have lost in living?
Where is the wisdom we have lost in knowledge?
Where is the knowledge we have lost in information?
- T.S. Eliot (1888-1965)
9 times out of 10 the computer is more valuable than the patient. They’re usually too old to know what’s going on (either normally or because of some acute change) or don’t know, don’t care or just straight up lying. Having previous information can help you when patients get tangential.
That said, if somebody can put together a coherent sentence their story is much more important than what’s in the computer. Unfortunately that’s rare.
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