medicine: From the physician’s point of view, the patient is a set of test results and numerical readouts. The patient as a person tends to be forgotten.

I saw this later in a different hospital in yet another ward. The attending physician would stand outside of the patient’s door and listen to the review of the test results by all the residents. They would then discuss the results and make further recommendations. Then, as we all left to go to the next doorway and the next patient, the attending physician would knock on the open door, stick his head in and say, “How are you doing today, Mr. Forbes?” That was the extent of patient interaction.

So many numbers, we lose sight of the person. Scientists measure what they can measure and pronounce the rest to be unimportant. But the most important parts of life are qualitative. One of the physicians on my study team told us that she is allowed only 15 minutes to attend to each patient in her internal-medicine practice, but it can take as long as 20 minutes to fill out all the required paperwork. She has to force herself to look at and interact with the real patient. One hospital center estimates that nurses spend only a third of their time in direct care of a patient. The remaining two-thirds is spent on documentation and medication record keeping. One physician told of watching a nurse who busily recorded all of the numerical indications about the patient’s circulatory and respiratory system, but was too pressed for time to consider the meaning of the numbers or look at the patient—a five-second glance would have revealed that

the patient was having extreme difficulty breathing.

Modern medicine is a complex undertaking. It is highly technical, highly specialized. The patient has been carved up into little kingdoms, with different specialties competing for ownership of each piece, leading to occasional flashes of territorial wars. Nowhere is this more vividly presented than in the operating room, where a vertical sheet placed over the patient at the level of the neck divides the territory belonging to the anesthesiologist (the upper part of the patient—the head) from the territory belonging to the surgeon (the lower part of the patient— the body). But even when everything works as planned, the complexity of the process— involving multiple specialists and disciplines—combined with the fetish for numbers and regulations, makes attention to the needs of the patient almost seem like an afterthought.

Those of us who have spent time in hospitals, in whatever capacity, know how frustrating it can be. All of us, friends, relatives, and even the patient, are all pushed aside in the interests of efficient medical care. And even where there is a caring physician or nurse attempting to help, nasty though well-intended legal restrictions block attempts of the patient and especially of relatives and friends to gain access to information.

The hospital is a complex system, with multiple complex interactions among people, equipment, laws, institutions, and a confusing wealth of information. The opportunities for improvement are numerous: Health care is a problem awaiting

Donald A. Norman

 

improvement, a problem that can keep many people occupied for many years. A problem so complex that we need to start now, for it is already life-threatening.

A final comment: Many hospitals recognize these issues and are working to improve them. Some have patient rooms with special areas for family. Others are trying to address the extreme attention to displays at the expense of the patient. Even more reason for us to be involved. The opportunity is right.

ABOUT THE AUTHOR Don Norman wears many hats, including co-founder of the Nielsen Norman group, professor at Northwestern University, and author, his latest book being The Design of Future Things. He lives at www.jnd.org.

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March + April 2008