It used to be that the paper chart was found on the exam room door. Before I entered I’d flip to my last visit, review my impression, check the plan and then enter. Then records went electronic. Now there’s nothing on the door.

This has lead to an interesting evolution in my process. Now after a moment of reflection, I just walk in.

But that’s not a problem.

I know my patients. I’m good at connecting faces to stories. When I see a mother’s face and she begins to talk, I can begin to tell her child’s story. I have the capacity to remember the most unusual details in the right context. Moms in chairs create just that context for me. The way she looks and sits and carries herself. Cadence of speech, accents, posture and other physical cues serve to trigger endoscopic findings, past phone calls and conversations. Kids are important. But, surprisingly, mom’s are somehow more critical in my process.

I start with wide open dialog. The easy exchange allows time for the details to present themselves. I’ve got stuff not available in Epic. Of course, in a perfect world I would study every aspect of EPIC before clinic. Instead, after this initial period of  neuropercolation I work my EHR for details. It supports what I uniquely know.

None of this is by design but by default. I started when I was left with nothing to review. Ultimately it’s been a happy mistake. If paper charts returned to the door I suspect I wouldn’t go back to my old ways.

I don’t recommend the cold exam room entrance for everyone. And I would never have recommended it for myself. It just happened.

Image via The Library of Congress/Flickr. Malaria poster in a San Juan clinic.