White Boarding

It’s not as much fun as a sliding board. From watching people use them I’m sure it’s not as much fun as a snowboard or a waterboard.


But for educational purposes I enjoy using a whiteboard in the office. I got the idea from John Mandrola who apparently stole it from Dr. Vartabedian. After using it for about a year I think I’ve got the hang of it. Understanding that “doctor” comes from the latin for teacher, it makes sense to use as many tools as possible to improve my communication with patients. What I’d love to be capable of doing is create a Doctor Mike Evans’ whiteboard (see video below) but I’m not anywhere that artistic. I’ve studied Sketchnoting and read the book but let’s face it, I’ll never be the artists my daughters are. Nonetheless, the whiteboard becomes a great place to list thoughts that are important while talking with my patients. Sometimes they like to add to the board:

My Patient's drawing

Dog walking done by a patient

My biggest use of the board is to list recommended healthcare sites, common causes of medical conditions and draw absolutely horrific anatomic drawings which at least make the patients laugh. Fortunately I am not paid for my artwork and hopefully Medicare will not be asking patients to judge that anytime soon.[1]


In the meantime, until my patients beg me to stop, I’ll continue to try to improve my illustration techniques and find new ways to communicate meaningfully with my patients. Here’s my discussion of lower extremity edema with causes on the left, a “vein” in the middle of the discussion and how to treat on the right. Maybe in a year or so I can write a before and after post on my improved abilities. We can only hope.



1. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/HospitalHCAHPS.html

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Post-its and the Practice of Medicine

Ever since the first Post-its® appeared in the early 80’s I’ve used the little colored sheets to remind myself about all kinds of things–telephone numbers, todo lists, shopping lists, dates to remember, notes for other people-especially my husband. I do not know how my mother, with her organizational genius, managed to survive without them.

When I began using a superb productivity program called Omnifocus, I thought my Sticky Note® penchant would be reduced. However, with the advent of EHR, I find it has done anything but. They clutter my desktop (my REAL desktop, not the one on my Mac) with quickly scribbled suggestions for changes requested or features not found on Allscripts (our EHR), thoughts for the blog, thoughts for future Vlogs, need for specific patient information, a book or website suggestion from a patient or my grocery list as I dream up an idea for supper tonight.

Later in the day I will quickly go through the stickies and move them to my calendar, Omnifocus, or if possible I’ll “just do it” (using a time-management technique by GTD® guru David Allen). They are ubiquitous in my exam rooms for writing quick info down with patients–a web site, recommended reading, an address, or medical term most often. Almost as frequently, they remind me to do something for a patient that would take too long to enter into the Electronic Health Record (EHR) or more commonly, it’s unclear where to put it in the EHR–like getting old records out of storage, obtaining recent ER notes, or looking up some particular disease state to research for the patient.

It’s clear that most other forms of paper will be disappearing from my office. Already the huge stacks of charts are disappearing, replaced with tasks or scanned documents in the EHR. Slowly, I’m beginning to appreciate the uncluttered appearance of my desk. However, I’ve found that its glass top, something I never used to see, makes a great surface for sticky note adhesive. 

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I Thought I Just Explained That…

Helping patients to understand the effects of lifestyle on risk-factors, explaining lab results and discussing disease processes, that’s all part of my job, right? Patients go through their lists and we discuss strategies for improving their health. When they have a disease process we discuss alternative therapies, causes and second opinions. I use a white board which the patients seem to like, for writing down important points or drawing anatomy or sometimes just suggesting a book I think they’ll like. I love the idea of participatory medicine and have “taken the pledge” to make this a priority in my practice. I’m blogging and tweeting and watching other blogs. I think I’m pretty good at making sure the patient understands his or her medication, disease, and followup before they walk out the door. Then a patient comes in and knocks me for a loop.

After a long discussion with a young woman regarding what I thought was an allergic reaction she walked back to the waiting room where my office staff overheard her say to her mother, “Dr. Nieder has no idea what this is and doesn’t know what to do for it?” WHAT?!?!???!?!?!? Honestly I spent a long time discussing what I thought had caused her reaction and how to treat it over the next couple of days. It was not severe enough for a prescription so did she think that without a medication she wasn’t “really” being treated? Was the fact that her presentation was puzzling and I was unsure to start make her think that I never put the puzzle pieces in place? Thank goodness her mom asked to speak with me!

Makes me wonder how many times I think I’ve been communicating just fine, when in reality what I’m saying sounds like all the adults in the Peanuts videos.


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This morning I was watching a TED presentation by Dr. Jeff Benabio who was speaking about his vision of our profession’s future. It was an interesting talk and I invite you to watch it but what struck me was the etymology of the word doctor. It comes from the Latin docere meaning “to teach”. Ah, it’s truly what I do all day long, with every patient. And perhaps that explains why primary care physicians have such low value in our society. After all, how well do we pay our teachers? If I was a proceduralist, a surgeon or interventional radiologist I’d be rolling in the big bucks. Maybe not as satisfied with my job, but hey, you can get satisfaction elsewhere when you make half a million bucks and year AND have three MONTHS of vacation!

Sorry, I digress…docere. This morning I explained the mediterranean diet to two individuals then recommended and demonstrated weight loss and exercise apps to them as well, listened to a woman talk about the sudden death of her husband last week (no education there, just listening), explained to my medical assistant why the prior authorization papers from the insurance company need to be put in the same spot in a 2″ thick chart so next year when we have to reauthorize her medication we can find it, discussed the myriad of causes for iron-deficiency anemia to a daughter so her mom could understand in Hindi why a colonoscopy and endoscopy is necessary, described the use of “eustachian tube exercises” to a musician with allergies who is having hearing problems (and why they work), explained how and why MRSA is now a community-acquired disease instead of just from health-care facilities and discussed how a young woman’s elevated blood pressure might be related to her increased use of NSAIDs. Wow, while I had this dim awareness of teaching, today was the first quantification of that in a typical morning and I am impressed. 

So it turns out that I really enjoy teaching, even though I would never have chosen it as a profession. Most of my patients are motivated to learn and want to make changes. While they may occasionally be resentful of what I tell them, most of them want to have healthier lifestyles and my middle class population has the economic wherewithal to hire a trainer, go to a gym, join Weight Watchers, etc. Slowly I’m incorporating tech in my educational tools–I routinely use my iPhone with patients, either looking up medications, treatments or diseases with ePocrates.

 My dream device would be an iPad, complete with anatomy apps that would give me an educational advantage while speaking with my patients. Someday, maybe….but my understanding, as we transition to electronic medical records (EMR), is that we will be stuck with a PC tablet and without the anatomy apps that make teaching so much more fun. Sigh.


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I love smartphone medicals apps

OK, let me confess at the start, I am a “techie”. I love computers, am a Mac groupie and was thrilled when my husband spent way more than he should have for my Siri-enabled iPhone 4GS. I have 271 apps on my phone. Sixty-three of these are medical apps developed for physicians of which I routinely use about 11.  By routinely, I mean every working day.

Recently, the Surgeon General had a contest called “The Healthy App Challenge” and announced the winners this week. I already use and recommend one of the apps, Lose It!, to my patients. Individuals log their activity, weight, goals, and calories. It has a huge database of foods and it can be customized. One can also scan in foods using bar codes (I scanned my potato chip bag barcode into the app today with my iPhone…maybe I shouldn’t be confessing to an occasional potato chip indulgence in this blog?). The website for Lose It! will import data from a Fitbit (another technology I like–my IT pedometer). since there are some studies suggesting patients who log activity and calories are more successful at losing weight, it’s a great app to recommend to patients.

The other winners include two guides that use smartphone scanning technology to determine the healthiness of a food product before buying–GoodGuide and Fooducate. Both interesting apps but not as comprehensive as the Lose It! app. The fourth winner (of four total), is Healthy Habits, an interesting and well-designed app whose purpose is to help the user change or develop new habits. It’s a bit addicting (in a good way) and the interface is both easy and fun to use. Although I have only downloaded Healthy Habits today, with the Surgeon General’s backing, I’ll likely be recommending it along with Lose It! for patients who really want to make some healthy changes in their lives and are tech savvy enough to enjoy using apps to do it.

Interestingly enough, I’ve read one doctor blogger suggesting that physicians should not recommend apps to patients due to liability. It seems like any tool that can help people change lifestyle for the better should be offered to people. Why does it seem that liability concerns sometime outweigh common sense? OH right–you have to talk to lawyers.

While I’m on the tech bandwagon, let me go back to the Fitbit. This beautiful piece of exercise equipment clips to waistband or bra strap, is unobtrusive, measures your steps, your calories burned, distance walked and can be worn at night to measure sleep efficiency. It’s a little pricey, $99, but not outrageous and the only true worry with it is just how long until it gets thrown in the washing machine. (Don’t laugh, I’ve been in panic mode more than once trying to locate it in the laundry basket.)

In the future apps will help us keep track of our own health as well as our patients. We will track blood pressures, glucose readings, heart rate, heart rhythm, etc, etc. Already an iPad was credited with saving a man’s life today. The future of apps is taking off today and it’s fun to be a part of it.

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