All 4 books by Edward Tufte now in
paperback editions, $100 for all 4
Visual Display of Quantitative Information
Paper/printing = original clothbound books.
Only available through ET's Graphics Press:
catalog + shopping cart
Edward Tufte e-books
Immediate download to any computer:
Visual and Statistical Thinking $2
The Cognitive Style of Powerpoint $2
Seeing Around + Feynman Diagrams $2
Data Analysis for Politics and Policy $2
catalog + shopping cart
Edward Tufte one-day course,
Presenting Data and Information
Denver, July 22
Seattle, July 25, 26
Portland, July 28
Minneapolis, August 22
Milwaukee, August 24
Chicago, August 25, 26
San Francisco, December 12, 13, 14
Medical information exchange: The patient, doctor, computer triangle
The usual concern is that patients feel left out with the physician is "looking" at the computer. How is this different than the physician looking at the paper chart? While in medical school many years ago I was taught not to make notes while seeing the patient and to do the recording afterward. In today's environment there is far more data to contend with than there used to be. Achieving ever more stringent theraputic targets are demanded of the physician.
The suprise has been the level of interest that patients show in seeing what is on the computer screen. Patients are participating in the data entry and editing of the data. I have heard that physicians are not that interested in graphs. They want to see the data. I think that this is a mistaken response to not haveing seen good graphs. The even bigger suprise is how interested patients are in seeing graphs of their lab results. This is not reported yet but in conversations with physicians from various countries this observation seems to be consistent.
-- Ray Simkus (email)
Response to Patient - Physician-Computer Triangle
There are, I believe, some empirical studies of doctor-patient interactions. Supposedly, an
early study reported that doctors on average made their first interruption after the patient
had talked for 18 seconds. The story has it that this 18-second finding produced
appropriate hand-wringing, and medical schools began to teach doctors to listen, listen,
listen. Years later, the study was redone; the first interruption now came after 24 seconds.
Here is a straightforward way to improve doctor-patient communication. In advance of the
meeting, the patient prepares a typed-out list of all the issues to be covered at
appointment with the doctor. This list should include causal speculations by the patient:
"This pain on my right side might be a gall bladder issue. A grandparent and my father
had gall bladder problems around my age." The patient should make several copies of
this list-agenda paper and bring them to the appointment.
At the beginning of the meeting, the patient hands a doctor a copy of the list. The doctor,
who did not get to be a doctor by being a slow reader, can read about 3 times faster than
the patient can talk. After handing the agenda-list over, the patient should look down at
her/his own copy, hinting that it is time to start reading. Or perhaps saying, "Here it all is,
read this." This may finesse a little joke by the doctor, "So, what's with the paper dress?"
(as the recent New Yorker cartoon had it).
The list gets everything the patient initially has to say out on the table, without
interruption. As the appointment continues, the list helps set an agenda and a schedule
for the allocation of time during the meeting. It also helps to make sure that the patient
does not abandon lower-level issues that should be discussed--because there the issues
are, already written out. Each item on the list is, in effect, checked off as the appointment
moves along. Perhaps the patient should even ostentatiously check off the first point on
the list after it is discussed to indicate that this list is what we're going to march through.
The idea is that the doctor is not only going to be looking at the computer and at the
patient, but also at the list. Because the patient keeps looking at the list.
The patient should bring several copies to the list to the appointment, since the patient
may see several medical staff members during the appointment. Each medical person gets
the agenda-list. For example, my doctor often has a medical student in training who handles the initial discussion and who then goes off to describe the situation to the doctor, who shows up later. Both the student and the doctor get copies of the agenda list. Multiple copies are particularly effective in the emergency room (if it is possible to prepare a list before going the ER!), since the patient will surely see a good many medical staff members at the emergency room.
The list-agenda enhances the efficiency, accuracy, and resolution of the information
presentation made by the patient. It also helps reduce socially or situationally-determined
answers to the doctor's questions; instead some of patient information has already been
prepared in advance, free of social pressure.
This list goes into the patient file and also assists the doctor in preparing notes for the
patient record. Maybe someday the patient provides the list via email in advance of the appointment; even so, the patient should still bring paper copies to the appointment itself.
Perhaps now and then such an agenda-list will even improve the effectiveness of medical care.
-- Edward Tufte
Response to Patient - Physician - Computer Triangle
The Pubmed abstract for the original 18 second article:
Beckman HB, Frankel RM. The Effect of Physician Behavior on the Collection of Data. Ann Intern Med. 1984 Nov;101(5):692-6.
The Pubmed abstract for the original 23 second article: Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient's agenda: have we improved? JAMA. 1999 Jan 20;281(3):283-7.
Recent work by the same authors: Schirmer JM, Mauksch L, Lang F, Marvel MK, Zoppi K, Epstein RM, Brock D, Pryzbylski M.
Assessing communication competence: a review of current tools.
Fam Med. 2005 Mar;37(3):184-92
-- Niels Olson (email)
The paper agenda-list goes after the key problem mentioned in research on doctor-patient interactions:
". . .physicians frequently choose a patient problem to explore before determining the patient's full spectrum of concerns."
"Physicians often redirect patients' initial descriptions of their concerns. Once redirected, the descriptions are rarely completed. Consequences of incomplete initial descriptions include late-arising concerns and missed opportunities to gather potentially important patient data. Soliciting the patient's agenda takes little time and can improve interview efficiency and yield increased data."
Another virtue of the paper list-agenda is an improvement, a large improvement I believe, in interview efficiency.
-- Edward Tufte
The blogger of Over My Med Body! introduces an interesting idea: pocket-sized pictures to illustrate to patients the anatomy of their particular disease. In specialty clinics the drug and device sales reps solve this problem by providing models and wall charts, but on the wards where patients have multi-system problems, that approach doesn't work.
-- Niels Olson (email)
A "master problem list" is a recommended feature of medical records, whether paper or electronic. (See a low-tech example for people or for animals.)
Sending this list to a patient prior to an appointment would jump start the formation of an agenda-list for that particular appointment.
Rather than creating an agenda-list from scratch, the patient would be reminded of past issues and could reassess their status and importance, and would also know what compaints his/her physician is or isn't aware of.
-- Alison Anderson (email)
The master problem list exists for every patient going to a routine physical. Interestingly, the notions of five-year and pre-employment physicals were brought about by a campaign at the beginning of the 20th century, first by the public health movement then happily adopted by the American Medical Association. However, the young and healthy don't really need the physicals, so the master problem lists were developed to tease something billable out of this rather large population group. The military's master problem list is DD2807, Report of Medical History. Service members fill out a 2807 before every physical (All DD forms). I don't know if the two methods, form and blank page, have been compared head to head, but the 2807 starts with the list and leaves about two thirds of its second page blank for comments.
Paul Starr provides an excellent social history of the routine physical, along with every other aspect of American medicine, in his Pulitzer Prize-winning, very anti-AMA, The
Social Transfomation of American Medicine,
published by Basic Books in 1984.
-- Niels Olson (email)
I've also seen master problem lists in some ERs, where the physicians actually have bins of forms they use to guide their interview and diagnosis based on the complaint (car wreck, gun shot, psych, head & neck, thorax, upper limb, abdomen, pregnant, gastrointestinal, urinary, genital, etc. The bins are actually stacked in anatomical order head to toe, with the high priority ones, like car wreck, on top). Neither of these, routine physical or ER, are the same as a typical clinic appointment where the typical middle-aged adult goes to the typical internist with the typical complaint of persistent heartburn and the typically present but sytemically separate history of chest pain on exertion three times in the last six months.
-- Niels Olson (email)
This thread has been quite interesting, and I can offer my own take. I practice in a primarily pediatric subspecialty practice, and as such, have the luxury of being able to impart information to the parents and other caregivers, in addition to the patient (if he or she is not an infant). One of the most useful things I have found if actually going over my notes with the parent.
First, I show them the growth chart, which shows in a very clear, graphical manner, how the child has been gaining weight and growing taller. This is especially useful in cases of patients I have been following serially.
If appropriate, I will go over the "family tree", as often the conditions I deal with have a familial basis. This also often helps clarify why I ask detailed questions about seemingly distant relatives. Seeing the tree graphically seems much easier than resolving a mass of text about "the mother's sister's second son...".
Additionally, our clinic visit charts are formatted to be a "checklist", such that normal findings can be checked off, and only abnormals need to be expanded upon. Parents, seeing the array of checks, instantly understand the depth of the evaluation, as well as the degree to which things are normal or not -- even without being able to clearly read or understand the details. They see that they are there, and that is often assuring.
Finally, our exam rooms have large posters with the body parts of interest (in our case, hearts) that we can point to. "Your child has a problem with this valve...", or "There is a hole here...". Seeing this up on the wall is often helpful for the understanding of teh parents, and of older children.
Of course, many of these strategies are specific, but I think may be applied in other clinical contexts.
-- Fraz Ahmed Ismat, MD (email)
My husband recently tried the "paper list of medical issues" idea at an appointment with his primary care physician (before I had read this thread!). He was rebuffed quite brusquely. Not only did the doctor -- whom he had not seen before -- show no interest in accepting or reading the list, she did not even give him time to summarize it for her. The appointment lasted only a few minutes. My husband has long suspected that at least some of his various troublesome symptoms are related by some underlying cause, but has been constantly frustrated in his attempts to find a doctor who will explore larger issues instead of just treating the most active symptoms.
Surely much of the blame for this episode lies with the particular doctor involved, the environment of the practice, and the procedures of our HMO. But it makes me think that Dr. Tufte's excellent suggestion will face many barriers in becoming widespread, even if patients embrace it.
-- Jennifer (email)
In my neck of the woods (which is to say, Canada) we are discouraged from bringing multiple complaints to the clinic. It's one complaint per visit, due to the billing structure and the need to keep appointments to a manageable duration. I understand some clinics are accommodating, allowing patients to book multiple concurrent appointments for multiple complaints. That said most visits to the clinic are for a runny nose or a sprained ankle, where problems are pretty independent.
A good doctor should explore all symptoms when investigating systemic complaints. Perhaps a good approach would be to address a "list of symptoms" for such cases. This differs from ET's suggestion only by its label: it doesn't imply a separate cause for each "problem".
-- Ashley Gadd (email)
Several have commented on taking a list of concerns to the doctor. I can offer this
I learned of lists as a child. When I needed something from Dad, any request agreed to
would be recorded on a legal pad. This was called "making the list." Nearly all items on
the list were eventually accomplished, but I learned coaxing was required to expedite my
urgently needed items. My later questions of "where exactly" within the list was my item
was met with an evasive "relax, you're lucky you made the list" or "it's on the first page".
Dad controlled the list, its length, and its ordering.
Even though as an academic physician I spend considerably more time thinking than
practicing, my patient care experience still yields me many lists from patients. From my
pespective, some of these lists help move the visit satisfactorily along, and others do not.
Harsh reactions from physicians to patient generated lists may have to do with ownership
of the visit. Within my own medical school class, it was telling that many of our promising
talent show skits never eventually worked because classmates fought over control of the
script. Acceptance of a patient list may seem physicians to represent loss of control of the
scope and length of the visit. Even physicians who regard patient lists with disdain would
welcome a chance to preview a certain complaint early in the visit as opposed to catch a
"Did I mention that I'm having chest pain?" in the 14th minute of the visit.
My biggest problem with patient generated lists; these lists often
seem like grocery store lists. This is not to say that there is no order, but rather that the
order is not apparent or not medically useful. The grocery list example can be carried
further: such lists are generated chronologically (out of cheese on Monday, out of soap
and bread on Tuesday), categorically (pantry items, bathroom items, refrigerated foods),
personally (items Susan needs, items Margaret needs, etc.), or by priority (Milk for the
morning!). While each of these shopping lists helps, the best, most-efficient list for
shopping is geographically organized (working the store from right to left). These lists
are harder to generate, as it takes an imaginary trip up and down the aisles to translate
the list into this format.
Generating a perfectly efficient list for a medical visit may be impossible for the
patient. A patient generated list often requires translation into a medical hierarchy. What
I often find myself missing is why is an item on a given list. Often I find myself spending
more time on a given item than the patient desired ("Oh that doesn't bother me than
much, I just wanted to know if it meant that I had cancer"). An explicit description as to
why an item is on the list, though, would help me. What about an
organization of: things I need today (refills, signatures on screening forms, or a disability
parking permit); symptoms that are bothersome or impair me that I would like some help
with (i.e., my knee gives out on me); symptoms I am worried about (I wake up three times
at night to urinate, I found it difficult to speak for about 10 minutes yesterday and now I'm
fine). That would allow me to delegate some tasks (other staff to assist with refills) and
reorder prioritize others (temporary loss of speech rather than nocturia) and to save others
for later, if needed.
-- Ted Johnson (email)
Response to Medical information exchange: Ownership of the visit?
Harsh reactions from physicians to patient-generated lists may have to do with
ownership of the visit.
Begging your pardon, but what do you mean by "ownership of the visit"? It
seems to me that the patient—you know, the person who is coming to
you for help—"owns" the visit. That doctors usually think otherwise is the
primary reason I refuse to go to one except in true emergency situations … or "take this
urine test to keep your job". I'm grateful that I can count such incidents on my ten little
-- Kurtis Kroon (email)
From the Boston Globe:
First, do no assuming -- A doctor urges his peers to think differently
By Sam Allis, Globe Columnist | January 28, 2007
"Fact: A doctor in this country interrupts a patient, on average, in the first 18 seconds of a visit..."
The article features observations by Dr. Jerome Groopman of Beth Israel Deaconess Medical Center, including:
"While the patient safety movement has led to major improvements in protocols to avoid systems errors, he points out, nothing has been done to address a more profound issue: how doctors think. And bad thinking is what causes countless mistakes. "No one talks about this stuff," says Groopman."
-- Jim Linnehan (email)
Interestingly enough, AHRQ (US Health and Human Services quality research agency) has a funding opp right now for what they call "dense information design" for the display of medical information, over time, graphically, to providers and patients. They note that "not having all pertinent information on the same screen" can increase errors (although they do not talk about poor and poorly integrated visual displays, which are rampant), and seek experts in "dense display of data and other innovative information design principles" (I would link to the grant app but it's actually open only to those with a specific contract vehicle; it's called "Use of Dense Display of Data and Information Design Principles in Primary Care Health IT Systems" and you can ping me if you're interested....I'm just a bystander in the process as well as a lurker here...)
-- Stanley Chin (email)
Evidence Based Medicine
I have been digging around looking at evidence based medicine. One of the very interesting websites is the James Lind Library that has a collection of materials on the evolution of fair tests of treatments from 2000 BCE to the present. It contains key passages and images from manuscripts, books and journal articles along with commentaries, biographies, portraits etc. As an example here is a page from a Chinese medical text from the Song Dynasty (960-1279 = http://tinyurl.com/6pb5oy.
-- Matt R (email)
I previously referred to the Veterans Administration's electronic medical record system, VistA. Having now used several medical record systems I stand by my statement that we owe those folks a debt of gratitude. Here is a VistA developer's opinion of the current controversy around Google Health and other online records custodians (which is the model I reported the AMA trustees envisioned would develop): Fred Trotter, In all Fairness.
In a related note, VistA code, being developed by government programmers, is available under the Freedom of Information Act and as such is continuously ported to the open source project WorldVistA. WorldVista developers have started working with the OLPC project to develop a Linux client. This has the potential to make widely accessible patient databases easily deployable all over the world, including in the immediate aftermath of natural disasters.
-- Niels Olson (email)
The article this press release is referring to is from a recent edition of Cancer. It speaks to many issues discussed across Dr. Tufte's forum topics. Present the appropriate information thoughtfully and patients will make better decisions.
Ben-Zion Wasserman MD
-- B Wasserman (email)