Twin Post Day: Why n=1 Really Matters - A Conversation with Docs on Twitter

"...the patient's perception is the core of the interaction..." - @DrCris

"The patient will always tell you what's wrong, you just have to listen..."
- @KittKlaiss

This week's successful post was going to be the long-winded, semi-elegant (or so I told myself as I spent nearly 2 hours typing it) diatribe on underutilized, subjective, individual patient narratives published below.

But something funny happened on the way to the forum.

En route to hitting the "publish post" button, I paused and thought - hmmm...it'd be great to get a doctor's perspective on why, when, and where in the care process a subjective patient narrative matters, like during the history & physical.


If I'd like to learn about how to become a better patient, and connect my subjective personal health narrative to my provider in a way that helps them treat me more efficiently and empathetically, shouldn't I just ASK why we conduct history and physical interviews the way we do? And learn more about how THEY learn to communicate with patients? And how THEY value (or don't value) patient narratives?

But where was I going to get this kind of access to doctors? What type of rarified environment and community would actually encourage this kind of exchange? I could think of only one.

So I posted the question on Twitter. And @symtym, @DrCris, @ruraldoctoring, and @KittKlaiss answered. Someone even brought snacks...

Two more hours later (amidst lively discussions of chinoiserie, color matching, and orifice differentials - don't ask) - what I learned about being an effective, empathetic patient:

  1. Your doctors don't want to miss a thing. They also don't want to waste your time, or theirs.
  2. Carry a current medication list in your wallet. That's right. Very Health 0.0025, but it works...
  3. Why are you there? What happened? What do you feel happened? What makes you tremble in the night?
  4. Take a lesson from chronic patients who do it right - keep information in your narrative clustered and congruent like a Nerds Rope - tight and sweet.
  5. Surprise: Your doctor is listening. He or she spends significant time gaining n=1 professional knowledge to conduct this H&P interview for greatest ROI.
  6. What is your hypothetical wish list? Why does it matter?
  7. Don't front load. It's like butting in line at an all you can eat buffet. Or screaming shamelessly for votes in the latest Twitter popularity contest. It works once, but catches up to you later.
  8. If you're going to bring up ancient history, make sure it is relevant to the issue at hand, at least until we get a kick-a#$ PHR underway....
  9. Give relevant details. She isn't asking about your holiday party exploits for her amusement (well, perhaps that story about table-dancing and spiked punch does serve a dual purpose...), but since you hit your head on the corner going down, you *may want to share that event when talking about your blurred vision.
  10. Alternate for 9 above - cut the crap. If you had 10 slides of 140 characters to tell your doc your concerns, what would you say (pure hypothetical)?
  11. Don't always count on the web to save you (or your fellow patients).
  12. Consider bringing cash money. Or dolls. Kidding! Maybe...
  13. Everybody lies. But try not to lie on this one - What do you want?
  14. See 13. Your doctor cannot read minds. Bonus: Neither can your significant other. Thank you for your attention to this matter. Your health definitely depends upon it.

Long and short of the subjective, patient narrative: It's vital for you to share. It's vital for your doc to hear, filter, analyze (and record). An antagonistic or diametrically oppositional orientation between patient and doctor can only be prevented with n=1 adoption from both sides.

Why are you there, after all? To seek care. Why is she there, after all? To deliver care.

These are complementary, not competing, goals.

Your narrative is a vital piece of the puzzle and your doc needs to not waste precious appointment time sifting through your data with the blunt instrument equivalent of salad tongs.

Being a proactive e-patient means adopting the n=1 orientation whole hog. Right and responsibility. What I heard from doctors tonight gave me hope that we haven't (quite yet) reached the mushroom cloud of mutually-assured healthcare system destruction.

As long as there are docs willing to take time out on Twitter, a social media channel for God's sake, to answer idealistic n00b questions about 'being a better patient,' there's hope for the system.

One even found it "fun!"

Doctors on Twitter - thank you.

The post below is self-serving, somewhat fancily written vaporware with some good soundbites and metaphors for chewing later. I won't delete it so readers can see the contrast. This post, relating our conversation, is the opposite.

That Twitter conversation will be the centerpiece of my "something promising in the system," a positive experience we've been asked to share at Dr. Val's on Healthcare Community Meeting December 30th, at President Elect Obama's behest.

It's a lesson I hope all those working for healthcare reform take to heart next year: Ask, don't assume you know what's important. Ask patients. Ask doctors. Whenever you're writing a whitepaper, or a blog post or a policy recommendation, ask first. Write later (or simultaneously).

Thanks to all of you on Twitter, here's what I learned this morning, sitting at the computer (but not sitting alone) re-learning how to be a good patient, and why I have more hope than cynicism moving forward...

The healthcare profession is n>1. Being a patient is n=1. But doctoring is also very much n=1.

It isn't the n=1 orientation that matters, although that is the first (and a vital) step.

It is the ability of each individual n=1 to be cumulative, to add to a larger aggregate that increases value, clarifies understanding, and promotes communication across professional healthcare constituencies. You've done that with me, for me, this morning.

Now, who's going to design tools *you'll actually value, based on challenges you see in real-world practice* that help you make better use of our time together?

And who's going to design tools that will help other doctors pick up the narrative when I see them?

That's a post for another morning of revelation...


Howard said...

Great post... It really boils down to listening. The patient will provide the clues...we need to recognize them. High Tech, high cost studies useful only when necessary to confirm diagnostic suspicion, not necessarily to make the diagnosis for a doc who is simply not taking the time to hear what his/her patient is trying to tell them.

Robin said...

Interesting post, especially the twitter dialogue. The problem I've found with doctor-patient communication is that the doctor thinks s/he is asking one thing when the patient hears another. It's not necessarily a lack of effort/trying, it's a matter of really understanding what the other is hearing as well as what s/he is saying.

A recent visit with an urologist ended with "I'm going to order an IVP..." and my response was, "I'm allergic to the dye...". His response, "Why have you had IVP's before?" Mine: "I had kidney stones several years ago."

Him: "Why didn't you tell me that?"

Me: "You didn't ask, nor could I get a word in edgewise. You allowed me brief answers and on you went." (Honesty...sometimes not the best policy but I'm pretty much gonna say it anyhow.)

Him: With a smile and nod, "Is there anything else I need to know?"

And I did give him a very succinct, 2-minute-or-less, rundown of pertinent info. He listened and did not say one word 'til I was done, probably because I was succinct.

Having said that, my experience with doctors has shown that about less than 1/10 really do listen. I'm afraid those who conversed on twitter are in the minority. I think we have on rose-colored glasses when we believe otherwise.

Kitt said...

Well, I'm pleasantly suprised to be quoted in such thoughtful blog! I've been seeing things from the provider side of the scale most of my life: my father worked for a Community Health Center when I was a kid, I got a Nat. Health Service Corps scholarship in med school, and came to a Community Health Center in rural Alabama 12 years ago. One thing I like about being in Family Practice in one place for a long time is that the learning goes both ways - I learn about the diseases and what works with communicating from patients, and as they keep coming to me, they (mostly) seem to learn to be better able to communicate to me what I need to help them. There is a lot to be said for continuity of care. I appreciate you listening to us.
Kitt Klaiss, D.O.

kirsti@extanz.com said...

Jen - great post -- as I get on my relationship centered care podium, I was glad to read your thoughts on this as well as your twitter conversations around the issue....my question is - how can we build this into health 2.0 more strongly -- I sometimes feel it is reduced to either patient or tech centric arguments.... where is the collaboration? the partnership? the mutual learning as Kitt points out? After all, isn't that why we are in this game, on all sides??


Inventory management software said...

Great post... my experience with doctors has shown that about less than 1/10 really do listen. I'm afraid those who conversed on twitter are in the minority. I think we have on rose-colored glasses when we believe otherwise.
It really boils down to listening. The patient will provide the clues...we need to recognize them It's a great idea on the surface