My online friend Bryan Vartabedian over at 33 Charts wrote a blog post on 2-18-11 about how he structures his patient interviews. Read it here. It gave me pause and got the wheels turning.
As I am interviewing you as a new patient for the first time, a lot of information is being shared (we hope!) back and forth. I ask questions, you answer, that leads to more elaboration, and on we go. The whole key to this process, of course, is to get to some kind of understandable, workable diagnosis of a problem that can then be better understood and treated, making you feel better than when you came in. That's the ultimate goal for me. I want you to leave feeling that you have learned something, gotten relief from your symptoms, or that you have a plan for tackling something that has been giving you trouble.
Bryan mentioned using a whiteboard to write things down as he explains lists of symptoms and key issues that might impact patient care. I have never thought of doing this in psychiatry, but it intrigues me. Instead of just keeping my usual notes on a clipboard to be used to type information into the electronic medical record after you leave, what if I actually got up and brainstormed with you at a whiteboard after the "formal" part of the interview was over? What if I wrote down key symptoms, possible diagnoses, and outlined potential treatment plans visually on a board so that we could both see them more clearly? It strikes me that at the end of a psychiatric diagnostic interview today, which is more like a thirty minute Board exam (pun entirely intentional) than a clinical encounter these days, that I fire an awful lot of info about disease states, medications, therapies, appointments, testing, and referrals at you than you might not be ready to hear right then. A visual aid might be helpful. There is the added bonus that I could then snap a picture of this information that we had covered and somehow get it into the EMR as well so that we can refer back to it later, reviewing and modifying what we thought about at that very first visit.
What do you think? Would a visual helper such as a whiteboard be helpful with communication in the mental health setting when you see a psychiatrist for the first time, or at follow up visits later? I'd love to hear what you think.
Thanks, Bryan, for this little nudge to my brain this morning.
There's no question that visual thinking would be helpful for patients in an outpatient psychiatric setting. Even simple bullet lists or basic three step flow diagrams make a huge difference helping a patient process a plan. It has changed the way I operate.
ReplyDeleteThis has been popularized in the book, Back of the Napkin. I found the book too involved but it supports this idea.
Bryan,
ReplyDeleteI'm going to seriously consider doing this in the clinic where I see "real" patients live two days a week. Could be interesting. I'll keep you posted.
Greg
There are electronic whiteboard solutions that allow you to type or draw (with a stylus). You can save your work or print it, and create templates for routine interviews. There is a whiteboard app for iPad but I don’t know how good it is.
ReplyDeleteI believe a picture is worth 1,000 words. If somebody is explaining something to me, visuals help me pay attention and remember. I sometimes use a flip chart or whiteboard when I’m interviewing stakeholders for requirements or process mapping. It usually reduces misunderstanding, but obviously some people get annoyed if they think we’re wasting time. If only I were a better mind-reader…
I think it is a wonderful idea. While I know this is not the same it is the only analogy I can make; I have a large animal vet that is notorious for drawing pictures in the dirt. When I had a horse going blind he drew an eye in the dirt and explained to me what was happening and because of the picture I completely understood. I have even taken pictures of his pictures. I am not comparing you to a vet I swear! I just know that pictures are helpful for understanding.
ReplyDeleteKY
ReplyDeleteI have thought about the iPad since I almost always take it with me, it's easy to use, it's cool, and it gets one's attention. I'll have to browse around for a good drawing, mapping app. Thanks for that suggestion. You read my mind.
Greg
Sandy,
ReplyDeleteThat's perfect, because the vet obviously makes getting the information across to you the most important thing, and he does it in real time using the real environment. I love it!
Never turn a blind eye to a vet who can draw.
Greg
I used to write or draw diagrams or use handouts all the time when trying to educate my clients. It gave them something to take with them to reinforce what I said and (I think) gave them hope that they really could feel better. They almost always appreciated that I took the time to do it.
ReplyDeleteGreg,
ReplyDeleteI'm intrigued.
My experience with a white board has been in patient rooms at MD Anderson. There each nurse signs in as the shifts change...some write messages..but for the most part the board's use is limited to serving as a giant nametag.
As a teaching and planning mechanism I think it would be awesome! It implies action and that something can be done to alleviate the patient's current distress/symptoms. Very cool.
Jody
I have used whiteboards when counseling on nutrition with pts. Bringing them to the brainstorming side of the conversation takes a bit of transition. Amazing results when the pt suggests changes and the professional is the guide.
ReplyDeleteGreat post as usual, Dr. S.
ReplyDeleteI'm not sure if I use a whiteboard/iPad that a patient could look at during the initial part of the interview (I'm usually taking notes about not just what they are telling me, but also what they are not), but using visual aids to explain final diagnosis and management plan is very helpful.
Some things I do- show patients how I scored their cognitive screening test (and what each category means in everyday terms), using graphs to explain the usual progression of different diseases (dementia, bipolar d/o, dysthymia), writing/drawing all medication changes and giving them a copy to take home with them.
Susan,
ReplyDeleteOne of my grandfathers told me many years ago that the one thing I needed to remember to do when I was finally a doctor was to "always give them something to take home with them". Of course, I have found over the years that this can be tangible (a business card, a phone number, a prescription, a written list of medications) or intangible (hope for the future). Either way, you've extended yourself, and they do indeed appreciate that you've taken the time to do that.
Greg
Jody,
ReplyDeleteI think that's what Bryan's post gave me the other day-an itch for the implementation of some kind of action that is different and maybe even unexpected in my patient population. They have been trained over many years to come in, regurgitate some symptoms, get a prescription and go home, just to do it all over again in a month or three months. That's not enough to inspire hope and recovery in my book.
Greg
Nicholas,
ReplyDeleteExactly! More guided involvement for the patient.
Greg
Hey Frog!
ReplyDeleteI'm with you, in that I have been used to taking notes on my almost thirty year old note sheet template at almost every visit. Helps me organize my thoughts and not miss anything in the bargain. I was also thinking that this might be a good intervention for that last 5-10 minutes of a thirty minute visit to wrap up and share/solidify the next steps for both doctor and patient.
Greg