We need the time to apply our noticing skills to our patients



If you think about it, that’s really a lot of what we do a lot of the time. As clinicians, we are trained as observers to notice, to use our eyes, our ears, our hands. To notice.

We notice that our patients seem different today. More tired. A little pale. Notice a change in their gait. Notice they are in pain.

We notice swelling in their legs, a new heart murmur, a telltale rash, subtle changes in the texture of their skin or hair.

We notice a gradual decline in their functional status. Less attention paid to their appearance, how they dress, their personal hygiene, how they interact with the world.

We notice a trend in their labs, a gradual fall in their hemoglobin, worsening control of their blood pressure or diabetes, more frequent visits for decompensating health conditions.

We notice.

The other day, I overheard a geriatrician colleague talking to the family members of an elderly patient, helping them synthesize what he already knew was probably going on.

He said, when they move less, when they talk less, when they eat less, that’s usually a sign that things are moving along.

It feels like the current state of our health care system has forced us into a position where we don’t have the time, the tools, the resources, to notice the way we used to, the way we should.

Running from exam room to exam room, patients triple booked, typing away in the electronic medical record, clicking away at all the boxes that need to be checked, the dozens and dozens of actions you need to take to order a flu shot or a medication refill, death by a thousand tiny clicks, takes us away from what we do best.

We notice.

A friend described seeing a patient recently for a second opinion, and she noticed that over several years of labs on this patient, her creatinine had slowly risen, all the while remaining within the normal range. It started at 0.4, then 0.6, 0.8, 1.1, 1.2, 1.4. Until finally, the lab value crossed the threshold of “abnormal” at 1.5, and was highlighted red, and suddenly set off alarms that made her prior physician start to pay attention to her chronically deteriorating renal function.

You can’t really blame anyone, there’s so much noise, so much we need to attend to, but unless we get the systems and technology and support in place to help us manage all of this stuff, it’s no wonder that our patients don’t feel attended to and we feel overwhelmed by trying to manage all of this stuff.

A patient recently came to us after her massage therapist who had been working some stiff muscles in her neck noticed a small lump.

This led to a more detailed examination by her primary care provider, imaging of her neck, and ultimately a biopsy which confirmed a diagnosis of cancer.

Shouldn’t we be the ones noticing?

We should be noticing their mood, their skin, a change in the way they look, talk, walk, and feel.

We were trained to notice, to synthesize and analyze, but if our lives are filled with endless bureaucratic nonsense and mind-numbing minutiae that has nothing to do with advancing the clinical care of our patients, then we’ve lost the opportunity to really care for patients, to help them get to the better state of health they want to be guided towards.

We need the time and the mental bandwidth to apply our noticing skills to our patients.

It’s not surprising that patients feel dissatisfied with the care we provide, when we rush into the room, spend a few minutes staring at a computer monitor, typing and clicking away and being frustrated, and then never get to their main concerns because we didn’t have the opportunity to notice what was really going on.

Remove the primary responsibility for most of this stuff from the physicians and other providers who are trying to take care of patients, and let us do our best to take care of them, to notice.

Believe me, we can use all the help we can get. We need people helping us extend the care beyond our brief office visits, nurses teaching patients about their health conditions, pharmacists helping them understand how to take their medicines, social workers helping them find resources in their community, care managers making sure that all the parts of the plan are in place and moving forward.

And technology can certainly be there, helping us spot trends, doing some of the noticing that we don’t have the time, or maybe just aren’t smart enough, to notice is going on in front of our eyes, or outside of the office.

How can we inspire the next generation of clinicians to want to enter this life, if they are overwhelmed in a training environment with refills of durable medical equipment, prior authorization from insurance companies, and endless messages flung at them by the electronic medical record?

It’s time we stand up and take back the process of taking care of patients, build a truly patient-centered care model that allows us to delegate and get all the rest of this done, without overwhelming us to the point where we cannot notice what is really going on in the lives of our patients.

If we take back the health care system, if we say enough is enough and demand real change, then our trainees will notice the difference, our patients will notice the difference, our own families will notice a difference, and we will notice a difference.

It’s time to give notice.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.

Image credit: Shutterstock.com


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