How an EMR makes connecting with the patient more difficult

I have the great privilege of being a medical educator. Everyday, I have an incredible time working with  internal medicine residents at their continuity clinic, teaching the art of ambulatory medicine. Our working environment here is academically rich and fulfilling. The name of the legendary Dr. Martin Leibowitz (an iconic figure in ambulatory medicine here) stands outside our conference room as a constant reminder of how medicine is practiced and taught. There is a large oval table at the center of the conference room, constantly surrounded by venerable attendings, interspersed with curious residents, discussing all the difficult cases of the day. There is the constant buzz of organized chaos like a stock exchange that is addictive and keeps things fun and enjoyable.

Although this positive vibe has never changed, the working environment has transformed since I first joined in 2009. The conference table used to be littered with text books like Harrison’s, Netter and a variety of dermatology books. In between the people and books sat  heavy, tattered orange colored paper charts. Some were just a few pages, some hundreds, all documenting a litany of complaints, physical exam findings, test results, insurance documentation, medication lists and well thought out plans by generations past of neophyte doctors. Blue, black, red, green ink on yellow oxidized pages, all fascinating yet often illegible. My intrigue with these historical documents quickly faded, and the burden of having to flip through hundreds of abstruse pages became quite frustrating. The sight of these bright orange charts piled on my desk at the end of the day, became a nauseating reminder of the inefficiencies and dangers of paper documentation. Our electronic medical record (EMR), slated to be release 6 months after my start date, could not come soon enough.

When our  EMR era began, it was a cataclysmic event. The process of seeing a patient with the computerized elephant in the room was a culture shock for some the attendings and residents. But we integrated slowly, utilizing a light schedule, and a lot of one to one attention for our residents. In 2 years we overcame a lot of the initial technical problems and are on our way to making this a very successful transition. The hardest part of this change for me, had nothing to do with my personal battles with the EMR. Rather, the presence of the EMR created an entire new domain of education I have to provide for my trainees. In addition to medicine, I find myself teaching how to create macros or imbed digital pictures into the electronic record. I’m teaching how to incorporate a myriad of digital tools to better care our aging complex population. It’s become clear that my role as an educator goes beyond teaching classical medicine. It also involves teaching how medicine will be practiced in the future utilizing technology such as social media and an EMR. As an advocate for the advancement of technology in medical practice, I feel fortunate to have an audience of bright trainees to share my enthusiasm about the future of medicine.

But this technological leap in our practice has had a price. Although the placard of Dr. Leibowitz remains steadfast, the working environment has drastically changed. The conference table often sits empty, replaced by several desktops sitting at the periphery of the room. All the textbooks stand neatly stacked in a corner, collecting dust, as Google images replaces dermatology books, and online resources replaces most texts. The sound of vibrant debate and chart perusal has been replaced by the clicking and clacking of keyboards. Whereas in the past, 50% of my encounter time would be spent discussing each case, and the other 50% seeing the patient, my attention is split in three ways now. 33% each , for patient, trainee and EMR. Now I have less time to get to know and personally connect with each patient. Now there is less time to discuss medicine with my trainees. For new doctors, I wonder if its more important to spend a few extra minutes to discuss how to manage a COPD exacerbation in the outpatient setting, than it is to teach how to multi-click and renew 14 medicines using “E-scribe”. With this whole new domain to teach, given the same time constraints, I’ve had to bring home work quite often, which  is begrudgingly easier now with an electronic record.

Despite these difficulties, I continue to love my role as a medical educator. The day to day issues are minuscule compared to the greater problems in medicine and society. I continue to stay motivated by the idea that my tutelage in medicine and how it interfaces with modern technology will prepare them for a future that will need doctors that are comfortable and successful in the both the real and digital realms.

Shabbir Hossain is an internal medicine physician who blogs at  Shab’s Sanatorium.

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