The computer had stopped the doctor from communicating

There was no mistake, but a bad thing has happened.  Despite the best efforts of the doctors, Bob’s wife is very sick.  Due to a rare side effect of treatment, her liver is failing.  Bob believes this could have been prevented. He is very mad.

“When we go to see the doctor, he stares at the computer,” says Bob. “He does not look at us.  Most of the time, the doctor is not even listening to us. He just sits there typing at the keyboard, gaping at the screen.  If he had been listening when my wife talked about the pain, then he would have stopped the drug.  Then her liver would be fine. She would be OK.  All you doctors have become nothing but computers.”

Now here it gets interesting.  After I listened carefully to Bob and sat with him at his wife’s bedside, I decided to check “the computer.”  There in the doctor’s records I saw a long discussion and analysis of the problem with her liver. Quite opposite of ignoring her, her doctor had listened, had changed therapy and was watching her liver carefully.  Sadly, despite the change, her liver had gotten worse. The problem therefore, was not that the doctor was not listening.  He definitely was.  The problem was that the computer had stopped him from communicating.

It is strange to think that a system of information and data exchange, which allows you to communicate with anyone around the entire world, interferers with connecting to the person right in front of you.  We see it constantly as cell phones, Ipads, computers and even that “old” obstructer the television, get between us.  At the time we need to communicate most desperately, electronics can block that most human connection of all, the physician – patient relationship.

Let us be clear.  Multitasking is a fallacy.  We can only do one thing at a time.  We cannot drive and text.  We cannot talk on a cell phone and listen to our mates.  We cannot watch a game on TV and discuss finance with our partners.  Most importantly, we cannot focus fully on a patient and a computer a same time.

Now, I am 100% committed to full computerization of the medical community and exam room.  The future of quality, medical safety, and cost containment can only come from full implementation of Electronic Medical Records (EMRs) with system wide analysis and the assistance of artificial intelligence.  However, right now is a tough time.  We need to figure out the new social mores’ and workflows, which will allow physicians to communicate with patients and with the electronic world.

Therefore, both physicians and patients need to learn new habits and establish slightly different norms for the doctor visit.  Patients must understand that for moments the doctor will look at the computer instead of directly at them, and not be offended.  Both doctors and patients should turn off their cell phones.  Doctors need to take time during each visit to look patients in the eye, instead of ogling the monitor.   Exam rooms should be set up to make this easy. It is one thing to type information (smoking history, dates they of medicines, type of surgery…) and another to ask tough personal questions while absorbed in a monitor. Doctors must never teach or give advice while at the keyboard. We must turn, see and touch our patients.

As Bob’s experience shows, even if a physician is doing the correct thing and paying close attention, the patient sees only an uncaring man staring at a screen.  The direct contact of the physician – patient experience is still vital.  Medicine is about people helping people and the cold interaction of the supermarket checkout line, will not suffice.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

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  • John Huyette

    Actually, I side with the patient in this case. I receive many EMR reports from various specilists, and when I read those reports to my patients later, they often say “He never did/said that!”

    • http://twitter.com/DRSALWITZ James C Salwitz, MD

      That is a key observation.  We can indeed be sucked so deeply into the machine that we forget to tell the patient what we are “communicating.”   It is so easy to document more than we actually say.  I have started to experiment with having the screen turned so that the patient can see what I am entering.  Have not worked out the bugs.  Part is allowing patient access to their electronic record.

      jcs

      • OETKB

        Voice recognition software is now at a level that with some practice it allows you to wait to the end of the visit to put in your SOAP note.  Medicine reconciliation, allergy history, past history, family history, and ROS if short can be typed in.  These engage the patient anyway.  Personal experience has its pitfalls, but using it for some 5 years I was done documenting before the patient left the room.  On the patient’s part they were ecstatic to hear that you heard and happy to make any immediate corrections needed.  My EMR was self made and I did not want to attempt it unless I could interact with the patient fully with such a tool.  Kids also get quite a kick seeing words jump up on the screen as you write them.  “Mom can I have that to do my homework?” 

        • http://twitter.com/DRSALWITZ James C Salwitz, MD

          I type quickly, so that has worked for me, but several of my partners use voice recognition with great success.  Whether to complete the dictation in front of the patient I guess will be one of style and relationships.  Obstetrician? Yes?  Oncologist? No?  In addition I have seen early software which can extract from a dictated note key words and populate a digital field.  One hospital at which I attend uses such software to scan dictated notes and assign ICD-9 coding.
          jcs

          • OETKB

            Before voice recognition I dictated all my records(later transcribed) in the patient’s presence.  Even sensitive subjects can be worded to be properly documented and show proper respect to the patient.  In 40 years of doing this I had no patient object to recording or to what was said, including discussing alcoholism, addiction, drug seeking, malignancies, prognoses, and diagnoses being entertained.  This kind of professional comfort, I recognize, takes practice but it was both a time saver for me plus a message to patients that their concerns were addressed and what my plan was to help them. In fact with today’s technology being what it is the methods of accomplishing this should be presented and taught in medical school or in pre-med colleges or universities.  

  • southerndoc1

    Texting while driving: prohibited by law.
    Texting while doctoring: required by law.

    • http://twitter.com/DRSALWITZ James C Salwitz, MD

      Fabulous.
      jcs

  • http://briarcroft.wordpress.com/ Emily Gibson

    Dr. Salwitz, you are making an important point.  Usually I do type as I listen to the patient, to be sure I accurately record their words and still be efficient from a time management standpoint.  I’ll often preface it by saying “it is important to me to record your history as we go so I don’t miss anything.”  When there is something that comes up that needs *me* more than it needs me typing, I stop, put my hands in my lap and off the keyboard to be fully present for the patient and not for the record I’m creating. It is a distinct change in my attention that I intentionally make. 

    I can’t save all typing and documentation until I’m out of the room or I would be perilously behind and then would be using up time excusing my lateness (which I’ve written about on this blog here http://www.kevinmd.com/blog/2011/06/reasons-doctor-running-late.html)

    Thank you for the reminder to “be present” when needed.  The patient is the point.
    Emily

    • http://twitter.com/DRSALWITZ James C Salwitz, MD

      Maybe “be present” would be a great slogan.
      jcs

  • http://twitter.com/Caduceusblogger Deep Ramachandran MD

    I enjoyed your article doc, very true.  I too wrote an article posted here of the difficulties of using the EMR. I have tried a few things to try to help patients’ perception that I am listening to them, while I am typing on a keyboard. One includes what another commenter mentioned, occasionally pausing and not typing. I also have gotten much better at being able to look at the patient while typing instead of the screen and using acknowledging statments, this lets them know that I am processing and thinking about what they are telling me and not simply documenting.  

    • http://twitter.com/DRSALWITZ James C Salwitz, MD

      There are indeed a set of skills to be learned.  It is not the same as writting.
      jcs

  • Ronald Yap

    I try to involve the patient while using the computer.  For example, looking at x-rays, reviewing lab data, looking at a pathology report can make it a more collaborative experience.  As far as documenting, I do this after a patient visit.  Some people are experimenting with scribes…anyone with feedback on this?
    Ron – http://prostatepals.blogspot.com

  • http://www.thehappymd.com/ Dike Drummond MD

    The primary purpose of the physician patient encounter is the connection of a human being who is scared and suffering with a caring, compassionate and competent professional. ANYTHING that interrupts this human connection will produce a visit with less patient satisfaction, compliance and a less effective course of treatment. The doctor does not enjoy it either …. as evidenced by our comment string here.

    Charting and coding are two of the top stressors and burnout producing tasks in any physicians day.

    IMHO more physicians might look at the “scribe” concept used in many ER’s. The doctor is the point of patient connection and treatment … someone else can manage the interface between the patient encounter and the EMR.

    My two cents,

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

  • Omada Idachaba

    So true! Very easy to miscontrue typing for ignoring but I believe that the often tense interaction between a physician and his computer and patient can be eased by letting the patient in on what is going on. I usually at the beginning of the visit especially for a patient I do not know well, inform the patient that I will be entering information of our visit in the computer during the visit. I do pause intermittently for a while to listen and then I continue typing. Sometimes, I type ‘aloud’ – say what I am typing, so as to let the patient know what I am inputting. For me, it has become more of an art and balance between patient, doctor and computer. I find that as long as the patient does not feel left out, they are ok with whatever you do with your computer.

  • http://pulse.yahoo.com/_UDJTUH45CFUC6LKCBLB6FGRDKU Diane

    Our dermatologist practice has been doing this for a couple years. For annual exams and for other visits. I thought it was a big waste of time for a short visit to renew some meds with the NP, but for an annual skin exam I can see it’s purpose. I’m not sure if the “scribes” are nurses (I know one was for my son since she introduced herself as such) or just good typers, but they are both male and female. I have a female doc and last year her regular nurse checked me in but a male typed. I just wasn’t sure what to make of the whole thing and honestly felt a little uncomfortable. This year a different male checked me in, discussed some new medical history changes and typed during the exam so I think he was the doctor’s nurse. They are in a new building and the room was large and he sat on the other side so I felt a little better. The other rooms didn’t seem as big but generally speaking, privacy wouldn’t be as much of an issue.

    It must be working well for them though. They seem to use them for all visits and for all the doctors and NP since 3 members of our family have seen them several times in the past couple years that they have started doing this. But I could definitely see the benefit of this for many other specialties and for anyone else who didn’t “grow up typing”. Hunting and pecking does not for a quick during or after visit emr chart documentation make.

    I can’t see this working at our family practice office. Though they are in a fairly new building, maybe 5 years?, the rooms are TINY and there is barely enough room for me and my 2 sons and the doctor when I bring them in. You really couldn’t fit a 3rd adult in there. So space is obviously a consideration. And if you need to be looking at the computer, it’s really just easier to do it yourself sometimes.

  • pendrasik

    Although I am not a doctor but a researcher for IT solutions in the healthcare field, I have seen this complaint many times before. My doc, who I went to see today actually for an annual physical, sits there with her chart (yes, paper charts even though the office has a pricey well know ASP hospital recommended EMR) and takes notes of which she inputs into the EMR during off-hours. She states the internet connection is too slow to keep pace with her workflow – poor implementation planning but that another discussion. Anyway, we definitely have face time, may be a bit shorter, but still it’s real face time.

    There are really good speech recognition S/W products out there that can assist with the doctor’s note taking (transcription services were also mentioned also as an option) but one option that I don’t see talked about much is having a large screen monitor in the room where the doctor and patient can discuss what is being added (verified) to their EMR records as well as being able to review lab results, x-rays. . . This should have been considered during the EMR implementation process but many times is missed or ignored as not essential. If realizing that this lack of attention, real or perceived, means the doctor could lose patients, would that now become essential? Well, I think so.

    Having the technology available to share the information together with a patient can go a long ways in alleviating this “losing face(time)” image. 

    If Bob had the opportunity to view / review the “Doctor’s. . . long discussion and analysis of the problem with her liver” on the room monitor, do you think he would have felt the same? Bob and his wife were essentially left out of the communication even though the doctor was performing his profession.

    Communications, it needs to be there but may need to be addressed differently when going digital!

  • Happydaysdoc

    My children and family have paid the price of having an EMR. I have donated 2-3 hours a night finishing up notes since 2005 that I can’t finish in the room because I choose to look at my patient instead of type. I blame EMR creators (Allscrips which I call Allcraps is ours) for not giving a hoot about how this impacts the doctor-patient relationship. I know eventually a person of high intelligence in the computer field will take on the healthcare field to give us a user-friendly interface, but why would they touch this tar-baby when they can make millions designing Angry Birds? I think the products we use are 1990′s tech shoved down doctor’s throats and we are buying it!! The problem is, doctors are too busy typing notes and trying to keep patients alive and well to protest their current situation! Google, Apple, ANYONE save us all from the pure H*ll of EMR!!!!

    • http://twitter.com/DRSALWITZ James C Salwitz, MD

      You are 110% correct.  The technology, especially on the data input side, is primitive. We desperately need to solve that issue for IT ever to achieve a major positive role in medicine.
      jcs

  • Amber Asaro

    I really appreciate this article.  I work for an EMR company and when I switched PCPs, I chose one who uses our software.  I was disappointed to see that even the way the room is set up forces him to face away from me to use the computer.  However, when I went to a physician who used paper records, she seemed to spend just as much time flipping through my chart and making notes.  Or my OB who used paper would just step out of the room for long intervals to make notes, write orders, etc.  I am sincerely trying to understand whether the computer is the true root of the problem here, or if it is something we could overcome with evaluation of office set-up and workflow. Also, couldn’t the same scenario have existed if the physician were furiously scribbling paper notes? I think there definitely is a long way to go to get the EMR really intuitive for most providers, but it seems that there needs to be a shift in focus toward communicating with patients rather than pure documentation, be it paper or electronic. In other words, I don’t think the computer is the only culprit.

  • RAStegwee

    The dictation in the presence of the patient, a postive experience mentioned in another response, can be replicated with an EMR when turning the screen sideways (or have a second screen) and have the patient read as you type. This is common practice with quite a few GP’s in Holland and other doctors
    are following their example. Instant quality control in most cases.