I had an interesting juxtaposition of events. While waiting in Peets, a coffee shop in Lexington Center, I watched the friendly discussions between the baristas and customers.
I then went to a doctor’s appointment, where a nurse stood typing at a laptop asking me a series of questions, including “Are you in pain?” and “Do you feel safe at home?” She didn’t look at me once as she read and typed.
Eye Contact with the Patient, Not the Computer, Is Paramount
Shouldn’t the intimacy of these questions mandate more eye contact than the less consequential discussions about today’s special roast and the weather? This is not jumping on the “customer” bandwagon, which has extended to some schools using “customer” instead of “student”. This is a matter of respect when asking personal questions and effectiveness at eliciting a meaningful response.
Ted Eytan, MD, MS, MPH, empathized with my experience. After his practice implemented an EHR, a patient told him, “You’re the only doctor who has looked me in the eye in the last 6 months of coming here.” Ted said, “It was like a dagger in my heart to hear that, and I am sure it would be for any other clinician.”
Computers in the Examining Room Should Not Be “Mysterious Intruders”
Danny Sands, MD, had great insights on what happens when a computer is introduced into the examining room. He said, “Interacting with a patient alone is a two-way conversation. However, when there is a computer in the room, it is part of the conversation. It both processes and provides information, and, because of that, it must be positioned in such a way that it can be a part of the conversation without being an imposition, just like if there was another person in the room.
Ideally, with a laptop or desktop computer, the computer would be at the apex of an equilateral triangle with the human participants at other vertices. With a tablet computer, the computer should be held by the user as they sit side-by-side. In either case, the screen should be easily visible to both (but it should be possible to temporarily shield it from the patient when necessary). Too often, as in the situation you describe, the computer is a mysterious intruder in the room, and the goal of the clinician is to interact with the patient only as a means to the end of entering the appropriate information into the computer program. This can be blamed on poor room layout, bad user habits, and badly-created user interfaces. Some would also blame the bizarre reimbursement system that rewards quality documentation above quality care.”
EHR Etiquette Should Include “Emotional Contact”
Pamela Katz Ressler, RN, BSN, HN-BC, similarly, believes medical professionals have prioritized information gathering over communication. She said, “While it is essential to collect information to arrive at a correct diagnosis, simply collecting information without addressing the human experience creates disconnection instead of connection; often leading to dissatisfaction by both the patient and provider.”
Joe Kvedar, MD, agrees with Pam about distinguishing between collecting necessary data and connecting with patients. When patients invest so much to get to and be in a doctor’s office, he believes, they deserve emotional contact including eye contact. Joe and I discussed telemedicine and how the “technical artifact of how cameras are placed on laptops” limits gaze awareness.
The different technologies for physician-patient communication all convey different types and amounts of information, Joe went on to say, and too much focus is on tools, rather than human communication. I remember when airports first used kiosks for check-in, and I answered questions on a screen about transporting packages that had been given to me by strangers. While I appreciated the speed of check-in, I felt less safe boarding a plane, hypothesizing that trained airline personnel might detect terrorists by tone of voice, facial expression, or body language. Just like, as Joe said, doctors obtain an enormous amount of information from looking at their patients.
Beverley Kane, MD, who teaches about EHR etiquette and worked with Danny on the first email guidelines for physicians, agrees. She noted the irony of how people tell their hairdressers more than they tell their doctors. Beauticians are often far more responsive and more sympathetic.
EHR’s Do Not Inherently Dehumanize; It Depends on How They Are Used
Following my experience with the nurse, the doctor walked in, shook my hand, and looked at me almost the entire time. He looked up one piece of information on the laptop in the corner – no triangle here – but it took under a minute.
My day ended at my acting class, where, coincidentally, we did exercises that focused on eye contact. In one, we tossed a ball at someone only after establishing eye contact; another was about the impact of physical distance and observation on intimacy. These exercises increased my own sensitivity to how powerful eye contact is, and how different stimuli, like touch and sight, can reinforce each other. Ultimately, better healthcare outcomes will come from verbal and non-verbal communication that is as attentive as in the coffee shop – or at the hairdresser’s.
Lisa Gualtieri is Adjunct Clinical Professor in the Health Communication Program at Tufts University School of Medicine and blogs at her self-titled site, Lisa Neal Gualtieri.
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