Doctors need more eye contact with patients, not computers

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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  • anonymous

    Uh, EHRs are about billing and administration, the business side. It’s about buffing the payers and the government and allowing the business people to make money by selling EHR systems. Loss of effective human contact is something that must be sacrificed for the greater administrative good. I thought everyone knew this.

    • SmartDoc

      Welcome to your eye contact free ObamaCare assembly line clinic of the very near future. You are so totally disempowered as a human being that even the third rate paraprofessionals never even look at you.

      Maybe the only emotional bonding will be to the hospital cleaning ladies who will at least look and talk a little with you..

      Real “Face Time” with a real M.D. physician will definitely be a selling point for any private practices that survive in ten years.

      • Not Savvy

        “Maybe the only emotional bonding will be to the hospital cleaning ladies who will at least look and talk a little with you.”

        I am not sure why Obama gets credit for this. This statement already expempifies my medical experiences-EMR or not. The only consistent care I get is from the lab tech… the only one that treats me like a real person. I am waiting for the kiosk in the waiting room. I will definitely feel safer.

        • W

          Agreed. The lack of “eye contact” typifies what I’ve experienced for many years (even with doctors who chart on paper — they’ll sit at a table in the exam room, back to me, scribbling away). Whatever the cause may be, I don’t see how it can attributed to the current administration and policies that haven’t even taken effect yet.

        • Brad

          Kiosks are already on their way, eventually they will replace the receptionist – which might not be a bad thing at some doctor’s offices.

          • Butch Phelps

            The sad part about this whole thing is, people get left out of the equation. We need people to be more educated about what their bodies need. Yet our parents have taught us not to be a part of the process and doctors have filled the role as the sole owner of knowledge because most really do not want to know. If they did know, the responsibility of their health would fall more on them. Your healthcare is a team effort. The doctor or therapist is only a guide, but ultimately your health is yours. Take it back!

  • Primary Care Internist

    But I thought computers were gonna solve everything in healthcare?

    • Butch Phelps

      A machine has no emotion, it cannot feel anything. Computers are great for storing data, but we still need humans to call gut calls. The legal has all but closed off gut feelings. That is to our detriment.

  • Martin Young

    I agree!! See my earlier post on KevinMD at about how technology has to adapt to our needs i.e. the patient and doctor !!

  • Edward

    Involving patients in what and why your are “typing” helps a lot. Voice contact helps, tell them what you are typing, similar to the dictate in front of the patient tactic to reinforce your advice. Also always speak positively about the EMR, nothing less productive than not having eye contact, complaining about it, and suggesting to the patient this EMR thing is something you don’t value. If patients believe you are documenting their visit so you can provide better care, they are usually more than happy to watch you type.

  • alex

    “If patients believe you are documenting their visit so you can provide better care, they are usually more than happy to watch you type.”

    But you’re not. You’re documenting their visit in painful, endless, tedious detail because the government demands you do so in order to not get audited and financially ruined. I have little hope this will change, but it certainly won’t change if we don’t tell our patients how “documentation” is constantly interfering with our attempts to take care of them.

  • Dr. Lawrence Kindo

    Computers are an end to themselves and should be cautiously involved in the clinical scenario. They do provide some important, if not essential information about the patient in a concise manner when called for, but detachment from patients and avoiding eye contact by the health care personnel undermines the importance of the patient and hence makes him/her insecure with his/her physician. Hence, it is imperative that a one on one interaction should always exist prior to involving a computer when dealing with a patient in the clinic or hospital. I believe in giving utmost priority to the patient and not the computer in the office.

  • RMore

    I believe a balance should be struck between documenting the visit and actually ‘seeing’ the patient. Giving the patient eye-to-eye contact should never be sacrificed for the sake of recording the event.

  • Martin Young

    RMore – tell that to a medical litigation lawyer!!

    I agree with you in principle, but when things go wrong there is a witch hunt, and the level of documentation is critical.

    We need to preserve what works in eye-to-eye doctor-patient contact, but enhance the documentation process. CLEVER technology can do that!!

  • visibility9

    Eye contact and resposiveness are all well and good but it is required to put all the patient data in the computer in a short period of time. You are penalized if you get behind schedule and what is more dehumanizing is scanning the patient like a grocery item to charge and reduce errors.The scanning is missed and that is more penalties and malfunctions. If the info was written down and entered later,you would be in a world of hurt.

    • Deb

      What works for eye-to-eye patient/physician contact and relationships is keeping medical transcriptionists in the loop to keep the narrative in dictation. MTs are losing their jobs due to “clever technology.” Not so clever, really, when docs have to spend half their time on this clever technology and not on what they do best.

  • LynnB

    SInce my practice when to the cream of the cr*p EMR 4 years ago I spend a bit over 1 hour out of the office for each hour of appointment time. When I took notes in the old way and then entered them it was 1.5 hours for every hour of appointment time. Too bad I wasted high school on all those advanced classes when I could have been preparing for my ultimate career in data entry for insurance companies who honestly believe they are trying to improve quality by seeing how many bullets I checked by taking typing and advanced typing.

  • Butch Phelps

    I was invited to be on a panel last week with a group of doctors in front of an audience of doctors about chronic low back pain. What was interesting was,2 of the doctors said the biggest mistake doctors make with back pain is they never actually touch the patient. They are relying too much on tests and scans. I couldn’t agree more. I had a patient last week diagnosed with scoliosis and told there wasn’t much they could do, then sent her to physical therapy. Physical therapy put her through some strength building exercises, which did not help. As a computer operator, and stressed, her neck, shoulder, and mid back muscles were as hard as concrete. Once I released the stress in those muscles and taught her how to properly stretch them out, the pain stopped. This woman had lived in pain for 8 months. We have got to have more personal attention!

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