Mechanistic medicine: Smarter devices make doctors passive

These days I often find myself looking away from my patients. The reason is that I am furiously typing the details of their office visits into the computer, thereby providing essential information to other doctors and staff members at the hospital.

Technology did not always intrude into the physician-patient relationship. Well into the 19th century, the medical encounter consisted mostly of a discussion of a patient’s symptoms followed by the doctor’s “laying on of hands.”

But in the late 1800s, devices like the ophthalmoscope and the x-ray came into wide use. These instruments improved diagnostic acumen, but they also distanced doctors from patients, according to Dr Stanley J. Reiser, a historian at the University of Texas Health Science Center at Houston.

“Those who possessed an x-ray picture could ponder and debate the medical problems of the patient without requiring his physical presence,” Reiser wrote in his book, Medicine and the Reign of Technology.

The need to document information in medical files was also a potential distraction. Some doctors waited to write their notes till patients left the office, but others preferred to write as patients spoke.

The electronic record has several virtues. “It is available when paper is not, can help coordinate among multiple providers and reduce errors,” said Dr James J. Cimino, professor of medical informatics and medicine at Columbia.

But like the 19th-century inventions, new technologies may be too alluring. The emphasis on entering as much data as possible into the computer ? patient comments, blood analyses, diagnoses, treatments ? can become all consuming.

Computer use may not be hard for clinicians who took their mothers’ advice and learned touch-typing. But as an inveterate two-finger typist, I feel uncomfortable when turning my head away to enter information. In an informal survey, my patients said they understood that putting things on the computer was part of my job. Yet patients may be unwilling to tell doctors what they really feel.

This is what led Dr Richard Frankel, a professor of medicine at Indiana University, to study how computers affect the doctor-patient encounter. The findings were published in August in The Journal of General Internal Medicine.

Frankel and his colleagues videotaped six physicians, two physician assistants and one nurse practitioner as they saw 54 patients, before and after computers were introduced to the exam room.

The investigators studied whether the clinicians maintained verbal and visual contact with the patients while using the computers. They also examined whether the clinicians turned their backs on patients as they typed.

The study found that in some cases, the computer limited communication. In one instance, a clinician kept her eyes on the screen for several minutes. The patient, frustrated, leaned far off the examination table to try to see what was being typed. In other cases, the typing clinicians responded with a grunt or “Yeah” to patients’ efforts to talk.

But others used the computer to enhance interaction: One doctor created a chart of a patient’s blood pressure readings on the screen to show the patient.

The Indiana investigators gave especially high marks to clinicians who adjusted the computer screen so that it ? and they ? faced patients. This brought doctors and patients physically closer and allowed patients to read along.

What do patients think of computers? In a companion study recently published in The Journal of the American Medical Informatics Association, the Indiana investigators found that more than 85 per cent of patients approved of the way their clinicians used the computer. Indeed, by seven months after the computer was introduced, most patients reported that communication had actually improved.

One of my patients, Gisele Gomez, largely agreed with these sentiments and said that she liked having her medical information immediately entered into the computer. Because she has been my patient for a long time, she said, she tolerates the fact that I now look directly at her less often.

But Gomez had a warning for clinicians seeing a patient for the first time. “I think that if I meet a new doctor and we don’t have that face-to-face contact, I would not feel comfortable telling him all my ills,” she said. “I would think he’s not listening and only paying attention to the computer.”  (NYTNS)