Shadowing

Yesterday, I spent the morning shadowing my colleague while he saw patients in our clinic. The goal was for me to learn how one doctor manages the flow of a busy clinic while still providing good care to patients and addresses all their issues.

I love shadowing. In residency, we rarely shadowed our colleagues or faculty. Life was too busy, too scheduled, too chaotic. We de facto shadowed specialists in their clinics on some rotations, but I had no personal investment in their practices, I didn't have to do their jobs.

Shadowing colleagues in my own clinic is different. Watching doctors with strong medical and communication skills, working efficiently with complex cases, is inspiring. In my post yesterday, I hinted at how a visit can get bogged down in chart review, and that there appears to be a better way to use the electronic record, on a screen, to engage with patients.

What I observed in shadowing this week was a great demonstration about how to use the screen as a visual aid in addressing concerns. There seem to be a few guiding principles I should follow:

1. Turn the screen toward the patient! What I can see, my patient should see. It's their health record, no secrets.

2. Exhaust the patient's list of concerns ("What's on your mind today? What else? And what else?" Until the answer is "that's it.") This I learned in medical school and residency. But now I'm learning to make sure I note it in the chart when the patient brings it up. I put their list on the screen for us both to see: our agenda.

3. Ask permission to go through their problem list (these are the things the patient is currently dealing with, things we should check in about frequently) to make sure it looks right. Patients who use our online service can view their problem lists at home. I also ask if we can look at the medication list on the screen, make sure patients know exactly what they're taking and what the meds are for.

4. Update lists and important information in the room, with the patient. It would be easy to think that this is a waste of time, especially when visits a stacked every 20 minutes or so, but I think patients appreciate it, and as we tend this clinical data, we're talking about a lot of health issues. The list work just gets us started and help us cover a lot of important ground.

5. Get it done now. I had a patient ask if he should take an antibiotic before his upcoming surgery. I told him I didn't know, but we should ask his surgeon. So we did, right away. I sent an email to his surgeon and the task was done. Or started, at least (we'll need an answer).

6. Summarize! Doctors review plans with patients all the time. Then both doctors and patients forget. Our electronic record has a very nice after-visit summary function into which I can type patient instructions, which I do in the form of a brief letter, noting what we agreed to during our visit. Again, I write this while the patient watches (I type fast), then review it with the patient to make sure I got it right. I print it and give it to them as I walk with them down the hall.

I'm sure there are more principles I can generate, but I'll stop there. It's getting late.

But before I go, one more word about shadowing. I learn so much from watching others do what I do. This was true when I was an actor, and it's true in medicine (also a performance of sorts). I think healthy medical practices should all encourage regular shadowing of colleagues so docs can pick up (and demonstrate) good habits and not get stuck in their settled inclinations.

Like Chauncey Gardner, I like to watch. I think we all should.