The human side of medicine that no computer can ever touch

As I look back all those years ago to when I chose medicine as a career, I suspect that my motives were similar to most people who enter this wonderful profession. I wanted to become a doctor because I had a genuine and sincere desire to help people. I also liked the idea of a busy and energetic job, one where I was comfortably as far away as possible from a desk or computer screen.

Lots of my friends may have liked the idea of a desk job, but I knew that wasn’t for me. Almost fifteen years have passed, and I still remember my first week of medical school like it was yesterday. All the experiences since then — the late night studying, the never-ending exam schedule, those exhausting rotations — have all been worth it, and I really have no regrets in choosing this path.

The scientific knowledge that we are imparted throughout our formal medical education gives us the skills to truly make a difference in peoples’ illnesses and suffering. But those of us who work in health care also know that the practice of medicine is so much more than the basic science behind illness. It’s about people. Every doctor gets to experience memorable interactions throughout their careers, as we treat some truly inspirational patients (who often end up teaching us many valuable life lessons).

Hippocrates once said, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.”

In other words, without really understanding the patient as a person, we are never really going to help them as much as we can. As an attending physician practicing hospital medicine at the frontline, I try my best to always remember this. Despite the challenges of modern medical practice, it’s always these one-to-one moments and the building of rapport with patients and their families that make being a doctor special; the noble profession that it should be.

But all nostalgia aside, it is this very basic premise of medical practice that appears most under threat in today’s medical environment, as the ability of frontline doctors to spend adequate time with their patients is shrinking faster than ever before. As I finish a 10 to 12-hour plus day, I often go home contemplating how much of that time I have actually spent with my patients and their families. Is it 50 percent, 40 percent, 30 percent? Inside, I know it’s probably much less.

Having worked in several different hospitals since finishing my residency, my experiences are not unique to any one institution. There is of course nothing new about this complaint. We physicians have been bemoaning this issue for decades. But there’s one crucial difference in our new technological age of medicine. Now, instead of demands to see more patients in less time or increased bureaucracy from insurance companies, it is the time we are spending with computers that is increasingly taking us away from our patients.

And sadly, most acutely affected are the frontline specialties where our interactions matter most — also including family and emergency medicine.

A much discussed study published within the Journal of General Internal Medicine focused on the work habits of today’s medical interns. The results made depressing reading. Interns now spend only 12 percent of their time in direct patient care and up to 40 percent in front of computers. Comparison to prior studies shows that this percentage has gotten significantly worse since the 1980s.

I can well believe it. In my capacity as a teaching attending, it seems to me that most times I seek out my interns and residents on the medical floor, I will usually find them sitting in their chairs, eagerly typing away on a computer or reading something online (maybe it’s because we conduct so much of our social lives online, or perhaps I’m a little old fashioned, but I always find something less studious appearing when I see anyone sitting in front of a computer as opposed to having their heads down reading or writing).

And far from this problem being unique to physicians. Glance down any modern day hospital floor, and you will see nurses — the very heart of direct patient care — frantically wheeling around their portable computers, glued to their screen, typing notes and scanning their medications. How much are we taking away from our patients when we give our nurses such excessive demands for computerized data entry?

One solution that is bandied around is to take computers away from desks and into patient rooms, performing all documentation tasks at the bedside. Unfortunately, this will likely be even worse for patient care. Looking at a screen and typing away for most of our interaction will reduce physicians to semi-automated, robotic workers — not that dissimilar from an airport check-in agent or shop cashier. It will be so impersonal to patients, not to mention annoying, when they are divulging the innermost details of their personal illness.

As humans, we always value personal interactions, especially when it comes to our health. We wouldn’t be impressed in any other industry if the professional we desired to speak to kept flitting their eyes in between us and a computer screen (none of us would even put up with it in a regular conversation). Hopefully this isn’t the future of medicine, although it sometimes appears like the direction health care IT is taking us.

All that being said, we must not forget the other side of the coin. We are living in an era of change like no other in human history. Science and technology are transforming health care in unimaginable ways, and the pace of change is only going to accelerate exponentially. Who can say with certainty that an iPhone won’t replace the stethoscope soon?

People are living longer and healthier than ever before and cures for previously hopeless diseases are on the horizon. Computers and information technology have brought enormous advantages to medicine in terms of information accessibility, data collection, and patient safety. Studies have proved the multifaceted benefits of initiatives such as computerized order entry. We still need faster access to complete medical records (those days when we trawled through piles of thick charts already seem so long ago). We also need greater communication between health care entities.

So, yes, medical technology is a force for good. Many doctors themselves have jumped on the bandwagon, and are dedicating their careers to health IT, often admittedly as a way of getting away from direct patient care. Fair enough, but I also question why anyone who seriously enjoys computers and sitting in front of screens more than their daily interactions with patients, would have became a doctor in the first place!

In my specialty, much of the increased time with computers is as a result of policies such as meaningful use and a transition over to computer-based charting. But there just has to be a better way of doing this. And that’s the key to this whole problem. How can we make sure that all of these computerized tasks that we are doing actually give value to what really matters – the patient?

So here is my advice for all the Silicon Valley entrepreneurs and IT whizkids (many of whom may have scarcely set foot in a hospital before) who want to create the new multi-billion dollar technology to “revolutionize health care”: Never forget the sacred doctor-patient relationship. Design your products with this in mind, and ensure that technology never comes in between the two. At every corner, enhance rather than take away from the interaction between doctors, nurses, and their patients.

Far from advocating a withdrawal from technology, the answer is to design smarter and better systems that promote ease of use and maximum time with patients. Certain features should be utilized such as rapid logging in to the desired screen, minimal clicking, touch screens, and more succinct data entry methods.

The only way this will happen is for all of us to work together, with frontline physicians and nurses fully involved in every step of the design process. Some IT professionals that I’ve met have asked me where opportunities lie for moving from pen and paper to digital. That’s the wrong question; it isn’t just an opportunity for business ventures (not to mention the fact that not everything we did in the days of pen and paper was wrong). The philosophy has to be about improved patient care.

So is this slide towards computers and impersonal medicine inevitable? It shouldn’t be, and it will be our generation of clinicians that will either allow ourselves to become semi-automated, or to keep the doctor-patient relationship where it rightfully belongs — at the front and center of all health care. The goal must be for the majority of our time to be spent with our patients.

Even if only 51 percent, that’s a start, as we tip the scales in favor of direct patient care. The course of the ship can still be turned, and collectively as a profession, we can do it. So when I next have that thought at the end of the day about how little time I’ve spent with my patients, I will remember that the deal is not yet done on the future of medicine. I remember that I’ve yet to meet a patient who thanks me for spending time in front of a computer. Until I do, I’m happy to keep trying to spend more time with them rather than my screen.

There are certain universal truths when it comes to humanity, and Hippocrates had it right over two millennia ago when he offered another pearl of wisdom for everyone in health care: “Cure sometimes, treat often, comfort always.”

That’s the human side of medicine that no computer can ever touch.

Suneel Dhand is an internal medicine physician and author of Thomas Jefferson: Lessons from a Secret Buddha and High Percentage Wellness Steps: Natural, Proven, Everyday Steps to Improve Your Health & Well-being.  He blogs at his self-titled site, Suneel Dhand.

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  • Ron Smith

    Hi, Suneel. Good post.

    Its been thirty years since I started residency. I too still remember the canned notes and class printing press, the lectures, and the awful name someone had for the head of the Anatomy department.

    I deployed my self-created EMR in 2000 and am still using it. Today’s Ferrari version is far from the Model T I first crafted. There are some very important caveats that I’ve learned about technology and my patients in thirteen years. Maybe these will be helpful to apprentice physicians.

    LOOK at your patient. Talk to them as though they are someone you really want to know and understand better. It doesn’t matter if you don’t feel the love at first, keep acting as though you do, and the feelings will come.

    LIMIT your nose-time at the screen when you are in the room with them. Read the history and have your first questions ready. As soon as you enter the room, make a comment that tells them you know why they are there, and go straight on to your questions.

    RECORD the important highlights in the EMR that come from your discussion in the exam room. Flesh out the rest after the patient is gone. I remind myself that I am a physician and not a court reporter.

    TEACH your patient as you go. Patients are not to dumb. They are eager to learn, They become endeared to you as a person when you do this.

    FOCUS on them. Push your own problems to the back of your mind. At the end of the wellness exams, I shake the parent’s hand, and looking at the father, I exclaim that they a great looking family! Paying your respect is the ultimate for patients and parents

    After the exam, I finish the chart. Then I lather, rinse, and repeat with all the rest of the patients throughout the day.

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • Suzi Q 38

      “…..LOOK at your patient. Talk to them as though they are someone you really want to know and understand better. It doesn’t matter if you don’t feel the love at first, keep acting as though you do, and the feelings will come…..”

      This is so true if you want good rapport with any patient. This is the best advice ever. Every patient deserves this attention, but some will not get it because of the attitude of the physician. I would hope that all of my doctors would have your attitude.

      “……LIMIT your nose-time at the screen when you are in the room with them. Read the history and have your first questions ready. As soon as you enter the room, make a comment that tells them you know why they are there, and go straight on to your questions……”

      I do not appreciate a physician who barely says “hello,” and begins to read a computer screen without talking to me first.
      I would hope that h/she could do this in his office away from me, before h/she examined me.
      I had a neurosurgeon who was very skilled at doing this. I was impressed, because he was a neurosurgeon, and they are not really known for their people skills. He would send his NP or nurse in first, who would ask me about any questions I had for the doctor. Some were very simple, and they would answer them. While this was going on, he was in his office, reading my history and reasons for being there that day. By the time he came in to see, me, he was ready to talk to me and answer the more complex questions.

  • rbthe4th2

    Dr. Smith,

    Your comments on LOOK at your patient, LIMIT your nose-time, RECORD the important highlights in the EMR, TEACH your patient as you go, FOCUS on them are dead on the money.

    I might add to that judge the patient, not the paper. I have seen this fallacy way too often, too much falling through the cracks, because there is too much reliance on tests without being able to interpret the meaning behind them, in light of the patients’ symptoms.

    Randy

  • rbthe4th2

    ‘In other words, without really understanding the patient as a person, we are never really going to help them as much as we can.’

    Right! In addition I would say that you can label them and then when you are wrong because due diligence wasn’t done, own up to it.

    ‘I also question why anyone who seriously enjoys computers and sitting in front of screens more than their daily interactions with patients, would have became a doctor in the first place!’

    MONEY, PRESTIGE, POWER, pretty much permanent employment/lifetime job security, and with no help from govt/regulatory bodies, the ability to screw up people’s lives and it not come back to haunt you.

    • Ron Smith

      Hi, rbthe4th2. Just a little light-hearted comment here, so please don’t take anything as an affront.

      Re: “MONEY, PRESTIGE, POWER, pretty much permanent employment/lifetime job security, and with no help from govt/regulatory bodies, the ability to screw up people’s lives and it not come back to haunt you.”

      Look I know that some people, maybe a lot of people, think that is what medicine is about. And no one going into medicine doesn’t think about the money potential at first.

      But money, prestige, and power are overstated and overrated for physicians I think. Job security for physicians can be equally and similarly viewed by jailed prisoners on a roadside work crew picking up trash with an armed guard driving along behind them.

      There is an enormous amount of effort and emotion that I give to my patients and parents. I’m keen on my responsibility to them as a physician and human being. Executives making similarly monies don’t generally have the amount of contact with the paying ‘customers’ as physicians do.

      Maybe someday I’ll have time to wring my hands in avarice all the while contemplating my God-like position… maybe by the time I’m 45 years into this! ;-)

      Warmest regards,

      Ron Smith, MD
      www (adot) ronsmithmd (adot) com

      • rbthe4th2

        I don’t take it as an affront at all! Btw, I finally got to see an internist from a medical school. They granted not only to do the testing that is supposed be done in December every year but they also LOOKED at my medical literature (one of the 2 items presented was by the medical schools’ specialty head, also was head of his specialties’ American College at one time, and YES doctors ignored that!) and gave me that full testing too!

        Thank you to the docs on here for listening and making those suggestions! I am SO happy and everyone else is also! Thank you!!! Now if only the insurance would cover the “internet visit”, I’d ask for you all to be paid for the consult! You guys deserve it!

        Dr. Smith, I don’t know if maybe its because we have two different views about medicine because of our experiences. You probably run with docs who are altruistic like yourself. I’ve seen some, have some. I notify their bosses how much I appreciate what they do. I make sure I can follow their directions or if not, say why. At the same time, I’ve had docs who are simply board certified who blatantly ignored a 5 min. presentation outlining major items, for people with my history, to look for and the resulting problems if they’re not watched. The presentation was by a doctor who received an award last year for major contributions over the years by his American College specialty, a former President of that college, and the medical schools’ specialty head. Now why would they ignore that? I’ve had docs who I say I can’t afford to see them at that time: their response: go elsewhere because you aren’t adherent. I’ve asked docs why they ordered a particular test because my problem was X not Y. No answer. Try one thing and quit.

        I’ve presented peer reviewed medical literature and said here, the links to the information is online. I’ve included that in the EMR. Their office notes said I gave them internet information, not peer reviewed medical literature. That’s a pretty blatant attempt to discredit the patient and make the doc look right.

        I have known functional issues, but the docs check structure or don’t check at all. Nor have my docs suggested medications that might address the functional issues. You don’t think that’s telling of their motives? What that says about the ability of doctors to think critically?

        You have to wonder about what or who they’re protecting when they can’t come to a decision, do recommended medical tests, or say everything is fine when the patient is getting worse. Why they want the patient to go out of the area for medical care that includes CBC and BMP blood work. Why they keep passing the buck that another type of doctor can fix the problem, when they refer me back to another one.

        I have seen a number of docs on here who are not those types I’ve experienced around here. I’m happy that there are still those left. I certainly do all I can to let the (I’m sure) tired and overworked docs who do help know just how much their contributions and sacrifice mean. I’ve made it clear I’m not sue happy. I just want someone to take a shot at what I’ve got, and try to logically figure out things that work. Go over what I’ve tried so far and lets see what I haven’t (and don’t blame the patient for reactions). Just deal with things so I can go back to having a life.

        When you see the opposite side of the coin, your viewpoint changes. I’ve seen it with several physicians who became patients and talked about their experiences.
        :) Dr. Smith, maybe together, we could see what we can do to get the types of docs I talked about on board. I think we would all benefit – and all without lining the lawyers and suits’ pockets – and putting the reimbursement levels back to the docs who EARNED that money. Isn’t that what you all got into it before third year changed the attitude?

        Randy

        • DoubtfulGuest

          Hey Randy that’s fantastic! Please do keep us posted as you feel appropriate. I’m sure I’m not alone here hoping that you get everything worked out and feeling bright-eyed and bushy-tailed as much as possible.

          Dr. Smith has lots of sage advice for us, although we might not agree on everything – that’s alright. ;) I, too, would be interested in some potential collaboration, although the docs probably know best exactly what we might accomplish and how. These respectful exchanges we’re having here (without lawyers in the way) are a good start.

          • rbthe4th2

            I agree. I think we could collaborate, but there is a concern I have regarding the responses to Dr. Wen on here. While I can understand disagreement, I saw responses that weren’t conducive to working together. I think this is a great start!

          • DoubtfulGuest

            Right…I sense there are a few lawyers behind the scenes here, too, so I’d better not be too idealistic. Just felt the leash tighten a bit…

          • rbthe4th2

            Maybe the lawyers would do well to help and not think lawsuit all the time. It might help their professional reputation a little better?

          • DoubtfulGuest

            Perhaps not as lucrative for them? Grrrrr…There is something called “collaborative law”, and a few good guys out there who do a lot of mediation. Everyone wants to feel needed, right? I’m sure there’s plenty for them to do without their forcing doctors and patients to be at one another’s throats.

            But then, jokes about lawyers might fall flat at everyone’s cocktail parties…uh-oh…

          • rbthe4th2

            I have no wish to be at any one elses’ throats. :) ROFL … I don’t know. Best buddy I’ve known literally all my life (families are close) is a criminal lawyer. Although he leaves names & most everything off, the few stories … are better than lawyer jokes!

          • DoubtfulGuest

            Agree, LOL. Criminal lawyer is a whole ‘nuther matter. For awhile when I was a kid, I wanted to be a defense attorney. Don’t think I would have been good at it…just was thinking to help people who turned out to be innocent. My injury lawyer after my car accident is a good guy, too. We didn’t ask for or receive anything excessive. There was no broken relationship in that case, just A Tale of Two Insurance Companies. Very impersonal. I just don’t like lawyers butting in where there used to be trust and teamwork (in the Drs. office).

          • rbthe4th2

            I agree on that. I think if people would keep their requests to what is really an issue that would help. If doctors and the like were honest about problems, I think they’d find it is possible we’d forgive them (I can live with small stuff) or if they/hospital would pay our share of the copays, etc. that would help. I can think of several of the hospitals around here sitting on cash, its not like $500 would hurt them.
            Unless the error rate is what I’ve seen, but maybe that would change the culture quicker to less admin, more medical help (I’ve not seen a doc who couldn’t use an extra pair or four of hands) and maybe a researcher for these docs. I think it would be good if these hospitals dropped some dollars on someone to send to docs the latest news and research. Come on, these docs don’t have the time to do ten tons of research. Some part time jobs for people who are savvy, etc. or college students, I think would help everyone.
            As for me, I don’t need a lawyer to take my research to a doc, for common sense questions, to get reviewed and answered. A lawyer is not going to give an attitude adjustment or help a busy doc.
            A patient with a mission … very different story.

  • JR

    So I went to a doctor to get a permission to return to work slip. The doctor walked in with someone else I was never introduced to. They both stood with their backs to me while they looked through my chart. They laughed and made some rude comments. Then they turned to me, with arms crossed, and told me to come back and get tested again in 6 months. I didn’t even know what tests had been run. Needless to say I never went back.

    My current doctor spends the appointment talking with me and recording notes on his laptop. At the end of every appointment he prints out a letter with our agreed upon treatment plan. If I’m getting blood work done, it will have every single test listed on it. It has things we are planning to follow up on and when we’ll follow up on them.

    Needless to say, I prefer the second EMR experience to the paper chart experience as a patient. I feel involved in my care. I feel I have ownership of my health.

    I keep seeing these articles about what’s needed to build a better EMR, with a complete lack of mentioning a usability specialist or doing usability testing. It’s a surprising void to me because UX is such a HUGE buzz word in the software industry.

    Most EMR software was written with “billing” as the top priority. The system is designed for the insurance companies first, management second, medical personnel is a dead last. If an EMR is built with “usability” as the most important priority, it will be a much better system to use. Truthfully, usability is usually considered important for customers, because business users (aka – medical personnel) can be TRAINED so many software developers will scoff at the importance of usability and instead say “they can be TRAINED to use the system so we don’t need to change the system to make it easier to use!”

    If you want to learn more about usability, start with “Don’t Make Me Think” by Steve Krug. But until usability becomes the focus, the EMRs will continue to be crap.

  • Anthony D

    Read this good article that came out in March of this year. Interesting one I must say!

    “Physicians may be marginalized as mobile tech engages us in healthcare”

    http://www.computerworld.com/s/article/9237358/Physicians_may_be_marginalized_as_mobile_tech_engages_us_in_healthcare

    • Suzi Q 38

      Like it or not, this is going to happen.
      We are going to have the technology.
      We have some of it already, in various gadgets and applications for our iphones.

      Dr. Topol is in San Diego, Ca., and is a “second opinion” cardiologist. You can get an appointment with him, but it takes about 3 months to do so, unless it is an emergency.

      I read his book “The Destruction of Medicine,” and found his ideas and knowledge very progressive.