Dr. Gretchen Berland, an assistant professor at the Yale University School of Medicine and former documentary filmmaker, writes in the New England Journal of Medicine of an extraordinary experiment she has conducted over the past 10 years. It involved giving videocameras to people in wheelchairs, and asking them to document their daily lives (samples of the videos can be seen here). The footage provides insight into the struggles faced by the disabled in conducting daily activities; it also provides a penetrating view of what happens during visits to the doctor, replete with considerable potential for communication breakdowns. At best, a common result is that doctors don’t get the full story of a patient’s condition; at worst, the patient can wind up receiving inadequate or improper care. Berland describes her findings as follows:
By the time Galen Buckwalter‘s physician knocked on the exam-room door, Buckwalter’s video camera had been recording for nearly 40 minutes. He had booked the appointment because his shoulders were hurting, and the camera recorded his view of the examination table, the comments he made while waiting and, eventually, a largely transactional and superficial exchange with his physician. Two weeks later, in his home, the camera would record a strikingly different take on his shoulder pain – a growing problem that, Buckwalter worried aloud, might cost him even more of his cherished independence.
As an internist, I was disturbed by the contrast between those two scenes, the second revealing the depth of Buckwalter’s concerns and fears, none of which were apparent during the conversation with his doctor. In the later tape, Buckwalter’s struggle is palpable. If such stark contrasts are common, how much do I really know about my own patients? Probably far less than I care to admit.
Berland candidly assesses a major flaw in our healthcare system, the various shortcomings of which Dubner has discussed before. Incomplete communication during visits only adds to the existing soup of unnecessary treatments, huge expenses, and potentially deficient coverage. Surely there must be ways, besides a basic “Yes/No” survey on a clipboard, to streamline the process of initial doctor visits so that patients feel comfortable giving physicians the bigger picture. Perhaps an online log that patients can fill out and doctors can review before the appointment, describing conditions and symptoms in detail, or even documenting pain levels for the few days prior to the visit? Any other ideas?
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Was it hidden video or not? I see the word “hidden” but not in the blog post nor in the linked article.
Brian Burke brings up an important point. As a patient it is in your interest to communicate effectively with your care giver especially as you know that your time with him is limited.
Having said that, in the dark ages (oh, about 30 years ago) a full medical history was considered a cornerstone of diagnosis. The clip-boards that have proliferated in the doctors’ offices recently, are an abomination. There is no substitute for taking your own history. A nurse or even another doctor will not do. With experience one develops shortcuts and the time to take the history decreases but cannot be eliminated altogether.
“I wonder if having patients give full histories to nurses and letting the nurses convey the salient points would work. That way, someone hears the full story, but it doesn’t require as much of the doctor’s time.”
At my university health services, I was “screened” by a nurse with unusual insect bites on my body. The nurse took down my information and concern about bedbugs, and then asked if I “went running outside at night.” I said yes, regularly, but that I had been doing so for longer than the bites… and she dismissed me without my seeing the doctor at all.
It turns out I had bedbugs.
Please check your assumptions and rethink your thinking.
For a solution you offered:
“Perhaps an online log that patients can fill out and doctors can review before the appointment, describing conditions and symptoms in detail, or even documenting pain levels for the few days prior to the visit?”
What makes you think the quality of information doctors need to make good assessments would somehow be improved by having patients type up their thoughts in an online log? Would “going online” somehow make patients more informative to their doctors? Are all patients equally literate? Would the act of pecking their keyboards make patients more accurate in describing ailments?
Please! Gimme a break!!!
Then you ask:
“Any other ideas?”
Well, here’s one: How about HOUSE CALLS???
Doctors used to go to people’s homes to examine them and speak to them about their ailments. It might just be that medicine — in proper practice — requires SOMETHING LIKE THIS to be effective.
My Great Aunt was a doctor who made house calls in the slums of Philadelphia, mid 1900s. The economic model for healthcare delivery in her time required it. The economic model for healthcare delivery in our time does not allow it.
Which leads to doctors who must practice an impersonal art, no longer connected to its purpose.
Worse than that, the new model creates patients — all of us — who have no “market voice.”
“Online” is not a solution for everything. “Medicine” is a special case in economics. It may just be that the art and science of healthcare requires social structures that don’t fit easily into market-based thinking.
As the patient noted above, my attempt was to discuss the need for more time from physicians along with better patient reporting.
But the effect of the physician-patient power differential and of years of paternalistic treatment on disabled persons, and I suspect many other long-term patients, is powerful. Many of us have been trained to under-report. If you are not stoic you must be neurotic–an attitude I have experience many times just since writing the NEJM piece.
This also raises the issue about something I’ve come to believe is the greatest asset of today: being able to communicate – to speak for yourself.
In my experience, a doctor appt for which I have fully prepared elicits a better outcome. If I wait to marshall my thoughts until I’m face to face with the doctor or nurse, I generally forget to mention something.
Some of the techniques like the “pain scale” which are used by the medical profession for communication of symptoms could be effectively used by patients.
Also, the role of the nurse could be used more effectively: she (or he) and we treat her position as being more a technician and less as caregiver. She and the doctor should draw upon her compassion, insight, and social skills as well as the checklists and procedures she is expected to use.
MD
Gaylen your words resonate with me and anyone I have ever known with a disability or chronic illness. I would go farther than stating the attitudes are paternalistic – they are downright patronizing. And being patronized by medical professionals is extremely debillitating so under-reporting is the norm.
Jen