Clinical Sketchnotes

December 18, 2012

imgresI just read The Sketchnote Handbook – The Illustrated Guide to Visual Note Taking, a new book released by Mike Rohde.  It details a method of note taking that I’ve been witnessing at major meetings over the last couple of years.  For the uninformed, sketchnotes are rich visual notes created from a mix of handwriting, drawings, hand-drawn typography, shapes and visual elements like arrows, boxes and lines.

The reason this caught my attention is that I use sketchnotes in my clinic.  I just didn’t know they were called sketchnotes.  Mine are on a white board, however, and they typically involve my teaching with parents.  The use of bulleted lists, titles, and schematic, cartoon-like anatomic images has changed the way my parents understand their kids and their problems.  It’s changed the way I communicate (my 2009 description of my white board activity).

What I’ve observed over the past three years is that this type of visual presentation of physiology, differential diagnosis, and plan represents an extremely effective means of capturing and sharing my our thinking in the exam room.  While EPIC is supposed to represent everything about a patient’s history and plan, I’ve found myself on several occasions hovering around a parents smartphone to review an image of my colorful 4×5 foot board taken from the original consult.  Parents love to take pictures of my clinical sketchnotes with their smartphones.

Here’s why visual thinking (like sketchnotes) works in a pediatric exam room:

  • Overwhelmed parents appreciate a simple boil-down of their child’s problem.
  • Parents can correct or modify facts appearing front of them.
  • Kids love seeing their doctor draw pictures.
  • The process demonstrates your engaged, active involvement in a child’s care.

This could be called clinical sketchnoting.  While this live, visual representation of concepts, ideas and data isn’t new, few health providers have applied it in the health care setting.

sketchnotePart of me wonders if this should be taken to another level.  Reading this book got me thinking: what about the use of sketchnotes to tell a patient’s story?  I can imagine a child’s story of abdominal pain captured in the way that almost instantly conveys the critical elements of the clinical history.  Instead of reviewing sentences and paragraphs of dry narrative during a follow-up visit, the snapshot of elements captured on a sketchnote would tell the patient’s story in a fraction of the time.  Typographic emphasis would draw us to the most important elements in the story or plan.  Perhaps a clinical sketchnote done in an exam room could be scanned in to EPIC as media.

Every clinician serious about communication should read Sketchnotes to see how elements of this technique can be applied in their setting.  We should experiment and grow with the way we deliver information our patients.

While you may think that you need to draw to create sketchnotes, Rohde drives home the point that it’s about hearing and capturing meaningful ideas, not the creation of art.  And my experience has been that once you learn how to draw simple intestinal villi (that become magically damaged with your eraser) you find yourself doing it again and again, each time with more efficiency and energy.

Sketchnotes is a quick, fun read.  The book is beautiful to hold and feel.  It is printed on heavy paper and has an indescribable velveteen feel to it.  Highly recommended.

Tell me what you think.  Have you had a doctor sketchnote your personal story?  Why not?

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{ 12 comments }

Mike Rohde December 18, 2012 at 11:20 am

Thank you Dr. Vartabedian for the review and sharing how sketchnotes dovetail with clinical applications. I do hope the book has a positive influence on other clinicians and physicians. Thanks again!

Mike

Heidi Roman December 18, 2012 at 3:17 pm

So cool! I’ll definitely look for the book. My “sketchnotes” are often on the paper covering the exam room table. You’ve got me thinking- have you ever created videos of any of your clinical sketchnotes talks? It would be pretty cool for a family to have the video and be able to go back and watch if they had questions later. For me, in general peds, it would also be great to have a series of “canned” sketchnotes talks on common problems that I could send to parents via email. . . or maybe one day even via text to their smart phone.

DrV December 19, 2012 at 10:32 pm

Funny you should mention that, Heidi. In my original draft of the post I noted that sketchnotes have been happening for years on examining room table paper. And that’s a good start. We just need to make it good enough that the patient can make some sense of it, take a picture of it or take it with them.

Great minds think alike.

Kirsten Ostherr December 18, 2012 at 3:31 pm

I love it, especially the part about the tactile experience of the book. Heavy paper and velveteen feel. Another to file under the column of analog vs digital. Some things really are better in person. Yet, the clinical sketchnote becomes much more powerful if incorporated into an EHR…

Todd Vandenbark December 19, 2012 at 7:46 am

I am a health sciences librarian, and during a class session in which med students were giving presentations on mobile applications relevant to their fields, one student took a different approach. Instead of evaluating an app that looked up drug information and the like, she showed us how she used a drawing program on her iPad to explain to her young patient and his family what an obstructed bowel was, and why it could be obstructed and the patient still have diarrhea. Wish I’d asked her for a copy of the image to share with others.

Nick Dawson December 19, 2012 at 6:45 pm

Just ordered the book and the timing couldn’t be more perfect. I’ve got this bucket list of stuff to finish after I wrap up this masters degree and “learn to sketch note” is like #1 or #2. Can’t wait to dig in.

DrV December 19, 2012 at 10:33 pm

Few books have got me thinking like this one, Nick. I think you’ll feel the same. Hopefully you got the paper form of the book. And thanks for chiming in.

Fraz Ismat December 20, 2012 at 10:20 pm

It must be nice to have a whiteboard in your exam room!

As a pediatric cardiologist, I have often resorted to drawing Mullins diagrams on the exam table paper for the parents. Our field seems to be particularly apt for a diagrammatic explanation of a child’s condition.

One advantage of drawing on the exam paper: at least they can take the drawings with them with or without a smartphone.

DrV December 21, 2012 at 9:58 am

I’ve had a number of remarks about the exam table paper, Fraz. I did the same thing in my old office. My problem is that it doesn’t convey serious intent to communicate, if that makes any sense. Sure folks can tear it off and take it. But if that’s the case, why not invest in some high quality pads and sharpies or bold gel pens? Also, the way we lay out our ideas and what we emphasize with typography, arrows, etc makes it more effective, IMHO. Do your thinking and tear it off. Consider taking a picture for your ehr.

It’s funny how we see whiteboards as a luxury. My 4-5 foot boards are under a hundred dollars. The impact has been priceless.

Susan Mathison, MD December 25, 2012 at 5:12 am

Hi Dr V,
So cool…. I’ve long been a fan of graphic facilitation of lectures (check out Brandy Agerbeck of loosetooth.com.) And I am often writing down books, websites for pts to check out on post-its to take with. But never thought about the white board as a clinical tool. Not sure that I have room for 4×5 wall mount, but just ordered a bunch of 8inx11in ones to try out. Thanks for your great work. Hope to meet you someday!

laura von kanel January 4, 2013 at 8:06 pm

Dr. V, as a RN/FNP seeing adult patients with chronic respiratory conditions in their homes for the purpose of improving quality of life and cost savings through reduction of unplanned doctor visits and emergency admissions…i was shocked to find that not one person/family out of my 80 patient caseload understood anything about respiratory anatomy, physiology or pathology. so i outlined my hand , added a couple of lines and some clusters, turned it upside down on myself and showed them the familiar ‘respiratory tree’. seeing this oversimplified illustration, they were able to understand where their primary problem was and how their use/failure to use their meds, follow environmental/treatment guidelines, etc. acutely affected their ability to breathe. their positive social and physical responses were so gratifying to me that i made this simple step part of my routine teaching protocol as applicable with patients of all age groups. children love their ‘respiratory tree’:) i make the drawing on the back of their standard ‘discharge insruction sheet’ so they have both instructions and illustrations/reminder on 1 piece of paper, and everything is personalized. your technique works, maintains the individuality of each patient, is cheap and contributes to a positive patient/provider relationship. i look forward to incorporating more sketchnotes into patient teaching and my own learning as i finish medical school and transition into practice.

Coniqua January 14, 2013 at 9:11 am

This is a great use of visual communication and I hope more doctors adopt it. To Heidi’s point of videos for common problems Dr. Mike Evans has worked with some professional graphic recorders to produce whiteboard videos on medical topics http://www.youtube.com/user/DocMikeEvans?feature=watch

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