The keyboard is the sworn enemy of physicians

During one long ago very hot Washington, DC summer, at the suggestion of my parents, I enrolled in a typing course that was given at our elementary school.

This was the summer between sixth and seventh grades, and there were lots of things I would’ve preferred to have been doing, but my dad, who started out in advertising, felt that touch-typing was a skill everyone needed.

I remember sitting hunched over those huge clunky typewriters for hours on end, with those practice worksheets stacked next to us, sweat dripping onto the keys. Sequences of letters in increasing order of complexity designed to build muscle memory and dexterity, consonants and vowels in groupings familiar and bizarre.

The quick brown fox jumped over the lazy dogs.

Try as I might, the QWERTY keyboard baffled my fingers and my brain, and I could never successfully type much of anything without staring at the keyboard and manually deciding where to put my fingers next and which keys to push.

Later, I proudly told myself that I had intentionally not learned how to type so that I would never have to take a job as a typist.

Of course, one of my first jobs after college was, you guessed it, typing out memos and fundraising letters for a small nonprofit organization.

But never did I think that my life in medicine would be so dominated by those keys, and my lack of mastery with typing.

When I first started out in medicine, there was no typing; we did everything, both inpatient and outpatient charts, on paper.

I can recall getting writer’s cramp as a third-year medical student on my first clinical rotation, when I finally got to do a complete intake history and physical on a brand-new patient.

Page after page of material I wrote, and probably no one ever read it.

As I moved on, into my sub-internship, then my internship and residency, and then as an attending faculty member, my notes definitely got shorter, and hopefully more clinically relevant.

We all aspire to create a useful document with our notes, something that can communicate what the patient told us, what we found on physical examination, and how we put that all together with our highly trained medical decision-making minds.

Everything else is just busywork.

So when I hear that we are all spending far too many hours typing away at our computers, both with the clicking of buttons and the free text, I think there’s got to be a better way.

We are not typists, nor should we be.

Just recently, I tried using one of the pre-templated features for a common medical complaint in our electronic health record.

These all have snappy names, designed to evoke a job aid that will make our lives faster and more efficient.

By bringing up these macros, one can march successively through it and end up with complete documentation of that complaint.

I tried it out, toggling along, selecting from drop-down menus, and even free-text comments, fleshing out the details.

In the end, I was left with something that read more like a Mad Lib than an actual clinical description of my patient’s symptoms.

We’ve all read these templated notes, where it feels like an endless regurgitation and an oversimplification of what’s going on with our patients.

There are certainly places where these kinds of fast and easy fixes may prove useful, but for the most part they don’t seem to capture the essence of what we are trying to do when we talk to our patients, elicit a history, do a physical exam, and decide upon a medical path to take.

No two patients are that much alike.

So, what’s the best solution?

Many of my colleagues use scribes during their clinical encounters, and I can see how this could be very attractive.

In the emergency room, and in certain specialty and subspecialty practices, a medical scribe stands unobtrusively in the background, translating and typing the details of the clinical encounter unfolding before them.

These are highly trained individuals, who know what to include and how to phrase things.

My worry about using these in primary care is that the exam room we are functioning in is incredibly small, and adding another person into this already tight space seems to invade the privacy of the doctor-patient relationship, and there’s really nowhere for them to sit or stand.

There’s also the model of the “virtual scribes,” where a recording device transmits the details of the clinical encounter, including the physician calling out their physical exam findings, to a trained transcriber located off-site.

While this probably takes some getting used to, it is certainly an attractive option, better than carpal tunnel, writer’s cramp, and me hunting and pecking at the keyboard.

For many years I’ve used voice recognition software (I’m actually using it right now to dictate this column) for the majority of the typing I need to do, content I need to capture that I would otherwise type, primarily in the HPI, physical examination, and medical assessment and plan.

Over the next few months at our practice, we are going to try several different options to see what works best, let everyone try something different and see what makes their lives easier, improves their efficiency, and doesn’t end up making everybody spend the weekend finishing up their notes at home.

I suspect that as technology continues to advance, we’ll be able to capture all of the data from our interactions with patients in every setting, from the emergency room, to the operating room, to the inpatient wards and the outpatient clinics, with the veracity and ease that we don’t currently have.

At the moment, we do the work twice, in the asking, and in the documenting.

Perhaps in the future, some form of natural language processing, voice recognition, AI, and machine learning will be able to effectively capture everything we do.

We may even get to the point where audio and video documentation will become part of our electronic medical record, just as digital clinical images are already starting to be incorporated.

Body cams, anyone?

Whatever the future of electronic medical records holds, we can only hope that they allow us to effectively and efficiently document our interactions with our patients, to create a more effective communication tool for collaboration between providers, and free us up from the chore of manual typing that even in the best of circumstances only detracts from the doctor-patient relationship we all treasure, why we went into medicine.

Or else we are in trouble:

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Fred N. Pelzman is an internal medicine physician who blogs at MedPage Today’s Building the Patient-Centered Medical Home.

Image credit: Shutterstock.com

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