Medical Student Reflection VII

by Academy of Clinical Excellence on October 2, 2014

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The use of computers and electronic patient medical records has changed the practice of medicine. There have been improvements in efficiency, storage and sharing of information, and analysis of data. However, the insertion of a computer screen between a physician and patient, in my opinion, has somewhat negatively changed doctor-patient communication. During my Miller-Coulson rotation, one of my goals was to observe how different faculty members have navigated this new tool and used it to their advantage in improving communication. Overall, I found that there is much diversity in how physicians use the computer system, but they can be divided into 3 main categories: (1) those who use EPIC throughout the patient encounter, (2) those who never touch the computer, and (3) those who only use EPIC as a reference.

Those in the first group write their notes on the computer while interviewing the patient. They go from looking directly at the patient to looking at the computer screen while they type. When I previously saw this as a medical student, it was somewhat jarring. I noticed there were times when a patient would share something serious or become emotional, but the physician’s focus on the computer would take them away from connecting with the patient. I noticed, however, that Miller-Coulson faculty make a point to position themselves so that their body faced both the patient and the computer screen, providing for better eye contact. The physicians would stop typing as appropriate when a patient’s story necessitated their full attention. Overall, I saw ways to mitigate the use of the computer through body positioning, eye contact, and a sensitivity to the patient’s emotions.

Those in the second group do not use the computer at all in the room. They sit with their body directly facing the patient, and with their eyes focused on them throughout the interview. Usually, this physician will have looked through the records the night before and jotted down some notes on a piece of paper. He or she may write other notes with pen and paper during the interview, to be typed into a note after leaving the patient’s room or later in the day. This approach is more time-consuming, as a search through old records and a writing of the new note must take place before and after the encounter. However, the physician is able to fully focus on the patient and is more focused on social cues, non-verbal behavior, and building trust.

Those in the third group enter the room, greet the patient, and make small talk before starting the interview. They do not type through their questioning, but they may look up records or imaging on EPIC, research a drug’s side effects, or just type patient instructions before the encounter is over. Typing or dictating the note is left until after the encounter is over. I believe this approach provides a nice balance of using the computer appropriately without it intruding on the patient’s story.

This topic of patient-physician communication in the era of the computer has reached the medical literature. I recommend a short opinion letter entitled: “Computer-patient-physician relationship” published in the International Journal of Clinical Practice. It references data showing that “gaze and eye contact are strongly associated with patients’ perceptions of clinician empathy and interest in the patient and with patients’ satisfaction and trust, which beget adherence and better ‘hard’ health outcomes.” The author suggests ‘five commandments’ to navigate the computer era:

  1. Go over the patient’s chart before the patient enters your office or before going to the bedside. Have command of the essentials.
  2. Once you have addressed the patient, maintain eye contact and utter concentration. Willfully avoid distractions such as checking on e-mails or calls. Never skip examination of the patient.
  3. If you need to consult a database, textbook, or guideline – do so at once and let the patient know. Most patients will appreciate your caution and thoroughness rather than despise your lack of knowledge.
  4. Leave all documentation and necessary printouts to the end of the encounter.
  5. Always finish the encounter by leaving the computer alone and personally addressing the patient, raising issues of health literacy, shared decision-making and summarizing the current encounter and future goals.

Overall, I think there are multiple styles that can work to smoothly integrate computers into our doctor-patient relationship. From the Miller-Coulson faculty, I learned various tactics to overcome obstacles of the computer, such as: body positioning towards the patient and away from the computer, ‘blind’ typing, chart review before clinic, and sharing the computer screen with patients. I’m grateful for the opportunity to learn from such great clinicians as I develop my own style of doctor—(computer)—patient communication.

Reference: Schattner A. “Computer-Patient-Physician Relationship.” The Intl J of Clinical Practice 2014, 68, 790.

- Shannon Walker, MSIV

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1 Comment

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Debra November 9, 2014 at 11:51 pm

While the EMR system, and all of the advances in IT are a good thing,. the sad thing is the loss of fresh eyes on patients. Many doctors use EPIC to per-judge a patient, based on opinions of doctors that can snowball from the first opinion, since doctors are now evaluating moods and other things that relate to well being. Such is the case with my history, and a lot of information was erroneous and I have had a hard time amending. I have experienced a nightmare in EPIC since i was misdiagnosed, and I think fears of liability have made a lot of abuse possible with this system in certain situations.

While we need these advancements, as they are highly helpful, save lives and provide prompt information on health conditions, we need to realize that doctors with no time, and overbooked schedules, are most likely not dealing with patients with fresh eyes, and often goes off of previous opinions. It can be a police like situation, where you are going to a detective interview vs. a pleasant medical experience, This experience with your physician or specialist is very important for motivation and healing. This doesn't provide this anymore with computers, and per-conceived information. If you have a complicated health history, and you have been labeled as depressed or anxious, that is even worse! That can caused a lot of problems with correct assessments. Transparency is needed in mental health information because doctors do not tell patients per-say what has been said or observed preciously, We can't judge a life or mood from 15 minutes, but these observations can have large impact on timely diagnoses. EMR's pitfall will be the dependency doctors are creating on other physicians , and not using a clean approach, or asking questions, as to there observations.

If more attention isn't focused on the doctors who tend to be into volume over quality, and a lack of transparency to the patient of previous opinions, he or she has no way to know, discuss, and get corrected information that is being gathered through meta data, other opinions, etc..It will eventually need to be addressed,as more patients become aware of what the health care industry knows and doesn't share, but doctors respond to and utilize in decisions. They wouldn't run an experiment like this, and so they must be careful of creating a pseudo patient, out of fears of our litigious world, and the discomfort they feel over mental health. It makes it very hard on those of us who don't plan to cash in on mistakes. We also need to realize that nurses, and receptionists are getting information, and there is a big difference in that relationship as well. We have a lot of work to do to make this as efficient as it should be. We need more focus on transparency to avoid misdiagnoses and failure to treat. This system could actually be a tort reform of sorts. Patients need to have accurate information, and the ability to see it, and change it, if it is wrong or erroneous. I believe the legal industry will be dealing with EMR laws sooner than later, and that is a shame. So much could be done collectively to make this good for the doctor and the patient.

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