Hearing Without Listening (NEJM)

It is 06:30, and the ICU is quiet as I make “pre-rounds” with other senior ICU physicians. We go from patient to patient, and today we can have meaningful verbal interactions with 3 of our 10 patients. In each of the 10 cases, the nurses who have been on duty overnight fill us in on events, assist with the exam, and help create an image of that patient on that morning. There are no computers in these interactions. Our connection with the nurses is real and human. They look us in the eye, and we give them our full attention during our brief interactions. We learn a lot from them. By 08:00 we are ready for work rounds.

Work rounds involve a large group: attending physician, ICU fellow, senior residents, interns, medical students, pharmacists, nutritionists, respiratory therapists, continuing care representatives, and outside each room, the patient’s nurse. Most of these people have their own computer, a workstation on wheels — a WOW. Our flock of WOWs moves from room to room. When we stop at a room, we review events from overnight, and since the relevant people have already examined the patient, we exchange information and make decisions.

How do our flock of WOWs and their operators deal with the task at hand? Thanks to the WOWs, we each have all the information in front of us. At the touch of the right keys, we can access vital signs, ventilator data, laboratory test results, imaging, consult notes, and almost any other piece of patient data. The presenter stands in front of the computer and describes the events of the past 12 hours, what was done in response to those events, and how well we were able to meet the plan made the day before. The presenter then summarizes the patient’s condition. Someone else reads the lab results, another person calls up the images and ECGs, someone else recites the list of current meds. As the various members of the group talk, everyone is focused on a WOW.

As the “teaching attending,” I watch and listen like a collie guarding the flock. I discover that very few people are paying real attention to the presenter. Most are staring at their screens, ticking boxes and checking data. Occasionally, the presenter will slip up and say something outrageous — “The potassium was 29,” instead of 2.9 — and no one will react. We eventually work through the ritual, satisfy the WOW’s need for checked boxes, and make a plan for the day.

To me it feels empty. Although we all participated, I don’t feel that we really got our work done on work rounds. We have a plan that the team will follow, but since there was so little intellectual interchange, it doesn’t seem that we as a group have really wrapped our minds around the patient’s problems. It’s not until we’re in a small group in the “doctors’ room” and the WOWs are on the sidelines, recharging, that the team members actually seem to communicate with each other.

One day, we have a pair of new senior residents. The resident running work rounds does not have a WOW of her own; rather, she calls on various participants — each with a WOW — to contribute his or her part. As we take up each patient’s case, she looks the presenters in the eye, which compels them to reciprocate. The residents who really know their patient’s overnight story don’t read from their WOW; instead, they look at the group when they present, and we look back. They consult the computer only on the rare occasion when someone asks a question to which they don’t know the answer.

Through the simple act of learning each patient’s information and ordering it in their heads, the presenters have synthesized the key elements of each case for communication with others. Instead of just reading aloud the information stored on the WOWs, we can now deploy our understanding of that information to make informed decisions that will advance each patient’s care. With this change, we and our computers have switched positions: rather than being our masters, they are now our servants.

Freed from the hypnotic power of our screens, we can once again engage with other human beings and pool our knowledge and expertise in satisfying and productive ways. Ultimately, that can’t help but benefit our patients. And perhaps our liberation will also lead to more immediate engagement with patients as well. Put in its proper place, the WOW becomes the instrument that allows us to both hear and listen.



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