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Dictation and the Patient
The article by Sutherland et al1 on dictating in the presence of the patient made some good points on the usefulness of this technique, but one important beneficial result was not mentioned.
During a patient visit, many items are discussed, some more important to the patient than to the physician.
When the visit is complete and the physician leaves the room, his attention may be focused elsewhere. As a result, minor parts of the visit are often forgotten and not included in the dictation. Often, these "minor" parts of the visit are important to the patient and should be mentioned again at the next visit.
It is easier to remember what was discussed while still in the room with the patient, and the patient can verify the accuracy of the dictation.
Gary W. Berger, MD
Hughsville, Pa
1. Sutherland JE, Egbert N, Gjerde CL, et al. Dictation in the presence of the patient. Arch Fam Med. 1998;7:281-284.
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In reply
I commend Dr Berger for his excellent letter to the editor regarding dictation in the presence of the patient. I absolutely agree with him on the importance of both the completeness and accuracy, which is enhanced, if not ensured, by dictating before distractions arise that diminish recollection of the encounter with the patient.
I agree that we did not make that point directly in our article.1 We indirectly implied it on page 281 in the discussion of the "closing moments" of the medical visit, on page 282 in advising the physician to "clarify the accuracy of the medical record," and on page 284 in stating "an extra opportunity for more information exchange, increased affiliation, and greater involvement."
I thank Dr Berger for stating it more directly.
John E. Sutherland, MD
Waterloo, Iowa
1. Sutherland JE, Egbert N, Gjerde CL, et al. Dictation in the presence of the patient. Arch Fam Med. 1998;7:281-284.
Arch Fam Med. 1999;8:196.
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