An elevator inspector named Adrian F.T. once told me that a machine can tell you it is safe and still be dangerous. Adrian has spent looking at the steel cables in the shafts of London office blocks. He carries a heavy flashlight and a notebook.
He told me that the modern digital sensors are very precise and they record every vibration of the car. The sensors send data to a central server and the server says the elevator is healthy. But Adrian still climbs onto the roof of the car. He looks at the way the grease sits on the rail and he listens to the sound of the motor.
“The sensors do not hear the sound of a bearing that is about to fail. They only record the temperature. The documentation is perfect but the machine is still broken. The record is not the thing.”
– Adrian F.T., Elevator Inspector
The Medical Elevator Shaft
The medical world has become like the elevator shaft. There is a mandate to document every second of a consultation. The doctors are told that this is for safety and it is for governance. They are told that the record must be legible and it must be auditable. This is true and it is defensible in a court of law.
But the surgeon has two hands and one pair of eyes. He has a limited amount of attention. If he spends of a consultation typing into a silver laptop then he has only to look at the patient. The patient is sitting in a chair and he is worried about his hair. He is worried about his face. He is worried about the way the world sees him.
Distribution of attention in a standard 60-minute governance-led consultation.
A Symptom of a Divided Mind
I made a mistake last week because of this digital world. I was looking at a screen and I was trying to log a follicular unit density report. I was also trying to reply to a message from a colleague. I sent a text to my plumber by accident.
I told him that the crown thinning was significant and we should consider a three-stage approach. My plumber replied and asked if I was talking about the pipes in the basement. I was embarrassed but I realized that I was not present in either conversation. I was merely feeding the machines. I was trying to make the data look right and I forgot to make the connection work.
The Geography of the Scalp
In a consultation for the best FUE hair transplant London, the details are everything. A man comes to Harley Street and he sits in a room. He is often nervous. He has been thinking about his hair for six years or perhaps .
He has looked in the mirror every morning and he has seen the change. He knows the geography of his own scalp better than he knows the streets of his neighborhood. When he speaks to a surgeon he wants to be seen. He does not want to be a data point in a governance spreadsheet. He wants the doctor to look at the way his hair grows and the way his skin moves.
The Fountain Pen Rhythm
The history of the medical chart is a history of slowing down. In the a doctor wrote in a leather book. He wrote with a fountain pen and the ink took time to dry. He wrote few words but the words were chosen well. He looked at the patient while he thought of the words.
There was a rhythm to the room. Now the rhythm is the sound of the mechanical keyboard. It is a fast sound and it is a hard sound. The surgeon is half-turned away from the patient. He is looking at a cursor. He is clicking boxes.
He is ensuring that the system knows he asked about allergies and he asked about family history. He did ask those things. But he did not see the patient’s eyes move when the patient talked about the surgery. He did not see the small twitch in the hand that indicates fear.
The Resistance of the Craftsman
Adrian F.T. says that the best inspectors are the ones who put the clipboard down first. They walk around the machine. They touch the metal. They smell the air. Only when they have seen the machine do they write the report. If you write the report while you look at the machine you see neither the report nor the machine. You only see the paper.
In the clinic, the doctor-led model is a resistance against this digital drift. When a surgeon leads the consultation he is responsible for the outcome. He is not a technician who follows a manual. He is a craftsman who uses a blade. The accountability is personal.
If the documentation becomes the primary goal then the surgery becomes a secondary event. The system is satisfied but the patient is ignored. The record says the consultation was comprehensive. The patient leaves and he feels like he was not there at all.
The Column for Identity
I remember a patient from . He was a tall man and he worked in finance. He had a lot of data about hair transplants. He had a spreadsheet of his own. He wanted to talk about the graft survival rates and the transection levels.
I could have stayed on my screen and I could have matched his data with my data. We could have had a conversation between two computers. But I closed the laptop. I sat and I looked at him. I saw that he was holding his breath.
He was not a man who wanted data. He was a man who wanted to know if he would look like himself again.
Trading the “Noticing”
The governance of medicine is a heavy thing. It is designed to prevent errors and it is designed to create a trail of truth. These are good goals. But we must ask what we are trading for this trail. We are trading the “noticing.”
The noticing is the high-level skill of the expert. It is the ability to see the one thing that is not in the textbook. It is the ability to hear the thing that is not being said. If the surgeon is busy typing “patient denies chest pain” he might miss the fact that the patient is clutching his chest.
The transition to digital records happened fast. It happened in the last . We were promised that it would save time. It did not save time. It shifted time. It took time from the bed and gave it to the desk. It took time from the face and gave it to the keyboard.
A Tragedy of Attention
In a surgical environment like Westminster Medical Group, the goal is to push back. The goal is to ensure that the surgeon is a surgeon first and a clerk second. The surgery happens on the person. It does not happen on the record.
There was a study done in a hospital in the United States. They tracked the eyes of the doctors. They found that the doctors spent more than 50 percent of their time looking at the electronic health record. They looked at the patient’s face for less than 25 percent of the time.
This is a tragedy of attention. It is a bankruptcy of the gaze. When we do not look at each other we lose the empathy that makes healing possible. A hair transplant is a physical act but it is an emotional transformation. You cannot transform a person if you are only looking at their digital ghost.
The Lying Control Panel
The elevator inspector Adrian told me one more thing. He said that when the cables snap they always snap at the point where the pulley hides the wire. You have to move the car to see the hidden part. You have to be patient.
You cannot see it by looking at the control panel in the basement. The control panel says the tension is fine. The control panel is lying because it can only see what it is programmed to see.
We are being programmed to see the checkboxes. We are being programmed to value the audit over the interaction. But the audit is a ghost. The interaction is the reality.
A Long Tradition of Observation
When a surgeon stands in a room on Harley Street he is part of a long tradition. It is a tradition of observation. It is the tradition of the keen eye and the steady hand. The patient deserves the gaze. He deserves the full attention of the mind that will soon be making incisions in his skin.
He deserves to know that the doctor has seen his specific pattern of loss and his specific shape of face. This cannot be captured in a dropdown menu. It cannot be recorded in a standardized field. It is a unique moment in time.
The Human Signal
I think about that text I sent to my plumber. It was a symptom of a divided mind. It was a warning. It told me that I was letting the digital noise drown out the human signal. I have stopped doing that. I keep the notes because I must. I follow the governance because it is right.
But I do the documentation after the patient has left the room. While the patient is there I am there. I look at the hair and I look at the man. I listen to the silence between the words. That is where the truth of the case lives. It lives in the parts that the software cannot find.
The digital log records the count but it misses the fear in the chair.
We must protect the space where the doctor and the patient meet. It is a sacred space in many ways. It is a space of vulnerability and it is a space of hope. If we fill that space with screens and wires we choke the hope. We make the medicine cold.
The best clinics are those that understand that the record is a tool and not a master. They use the tool to support the care but they do not let the tool replace the care.
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