Should I be Human, or a Computer?
It is hardly news anymore that electronic health records (EHRs) are the bane of many doctor-patient relationships. EHRs are often detested by doctors and viewed at best with mixed feelings by patients, as a necessary evil to achieve the advertised benefits of digitized records. Patients now typically see their physicians spending most of their time interacting with a laptop during consultations, instead of looking at them as they had done previously. Naturally, the patients then often feel like second-class citizens, with the doctor-computer relationship apparently now more important than the doctor-patient relationship. In turn, the doctors are severely pressured to constantly use the EHRs, both to fulfill administrative demands within hospital environments, and to check off scores of boxes on the computer screen to satisfy insurance requirements for payment – moreover, generally at reduced rates. Many of my colleagues tell me that they now spend several extra hours each day on computers, typing while seeing patients, between appointments and late into the evenings. In a recent survey of about 35 interns in several hospitals, Stephen Bergman, Professor of Medicine at N.Y.U. (and author of the novel The House of God under his pen name Samuel Shem) reported that the typical percentage of time spent in front of a computer screen and typing in the data during a shift is 80-90% percent, leaving minimal time for face-to-face doctor patient contact. This is all part of a broader malaise, in which the business and administrative components of healthcare have come to take clear precedence above other needs of doctors and patients, for instance, quality of life issues. On point, last year the American Medical Association called for a major overhaul of EHRs to make usability and high-quality patient care higher priorities.
The Eyes Have It From a strictly diagnostic perspective, much may be lost if a doctor spends only a short amount of time actually looking at his or her patients. About 20 years ago, Irwin Braverman, a nationally prominent (now emeritus) Professor of Dermatology at Yale recognized a critical need to improve observational and diagnostic skills in his medical students. Dr. Braverman then took an unusual means to achieve his goal, developing a course to teach first-year medical students to improve these skills by carefully studying paintings (at the Yale Center for British Art) as if they were surrogate patients. This shortly thereafter became a required course at Yale, and subsequently has been much lauded and emulated by many other prominent medical schools. And the greater attention to visual cues certifiably works — according to a study published in JAMA in 2001, students’ abilities to pick up on important medical details significantly improved on the basis of this approach. The students learned that the more time that they spent carefully looking at a patient, the more likely they were to notice something that a cursory glance or tests would have missed.
Indeed, I came to appreciate the importance of careful observation on my very first set of rounds while I was a medical student, a lesson that I never forget. The resident who was leading us diagnosed lupus in a patient who was complaining of severe abdominal pain. What prompted the young doctor to make this remarkable (and correct) diagnosis, which at the time floored me as both miraculous and beyond the reach of any mortal observer? Our resident astutely commented that the beds of the patient’s fingernails showed irregular, twisted, and dilated capillaries, or as he said in his regional twang, `linear cuticular telangiectasia`. I surely would never have proposed lupus as a primary differential (diagnosis) based solely on listening to the patient. As I subsequently came to appreciate, the visual appearance of the fingernails can in fact provide clues to a number of underlying systemic diseases. For example, clubbing (colloquially called `drumstick fingers`), which is often associated with lung or heart disease, was first described by Hippocrates in the fifth century B.C.
What else might be lost in this Brave New World? I am especially concerned about the potential loss of trust and openness, which is paramount in a thriving doctor-patient relationship. As suggested above, EHRs tend to squash any rapport between the doctor and patient, reducing the interaction to pure process. I am sadly reminded of a definition that I learned in college, namely that a lecture is the process by which the notes of the professor become the notes of the student without going through the minds of either. However, there are substantial health care benefits in the human interaction between doctor and patient. Studies have shown that patients with close, personal bonds with their doctors and shared engagement with their care are more likely to follow their prescribed treatments. Even placebo effects can be real and strong. The ability to really listen, to pay full attention to tone and cadence, while reading emotions, facial expressions, and body language, is a skill set that is developed throughout medical school and residency, and allows the attuned doctor remarkable insight into a patient’s hopes, fears, and expectations. Must this all be forfeited in the name of productivity? What about empathy, compassion, comfort, and counsel? I see my role to be a partner in a quest for a patient’s best health and quality of life, a coordinator of integrative care, as necessary, and a zealous patient advocate, certainly not an automaton. Good medical care is considerably more than data management.
A reexamination of several important settings should amplify my concerns here
In Sickness Both ductal carcinoma in situ (D.C.I.S.), often referred to as Stage 0 breast cancer, as well as prostate cancer in men, illustrate the issues at play. Screening to detect either of these diagnoses is very controversial, with ongoing debate amidst a large body of equivocal or conflicting evidence of utility, and frequently shifting guidelines. `Do I ever need to test?`, `At what age should I start?`, `How often do I retest?`, and `What to I do with a positive diagnosis?` are all questions that require a personalized response. More acutely, most patients with a fresh, positive diagnosis will be somewhat confused and scared, and should want guidance that is individualized, incorporating both their history and their personal belief structure. Should a woman just diagnosed with DCIS undergo surgery, and if so, is a lumpectomy or a mastectomy the `right` choice? If lumpectomy is chosen, should it be followed by radiation therapy? Is nonsurgical `watchful waiting` (active surveillance) a better option, and if so, what tests should be taken to monitor disease status, and with what frequency? As Siobhan O’Connor recently wrote in a timely and cogent feature article in Time Magazine on this subject, “doctors are learning that a one-size-fits-all approach isn’t working.” If surgery is elected, most women still have vital concerns regarding body image, sexuality, and attractiveness to their partner, and as always, surgery comes with potential complications, especially if a mastectomy with reconstruction is involved. For men with a recent diagnosis of prostate cancer, the fog of information is particularly problematic because surgery and radiation treatments can have serious side effects like incontinence and erectile dysfunction. Patients receiving either a DCIS or a prostate cancer diagnosis need to explore the options thoroughly before making a decision that depends heavily on the risks that they are willing to take.
Although in the abstract, patients are aware of many of the above issues, let’s now reconsider the patient’s actual decision-making process in the face of a positive diagnosis. Many patients will prefer to defer to their doctor’s recommendations as to how to proceed. But these are life-changing decisions that we are discussing, and I want this to be a joint (and ongoing) discussion, not a unilateral directive. Most decisions ultimately will be driven by subtle and nuanced personal considerations, balancing programmatic data based on diagnostic findings and medical history with not only my patient’s risk tolerance, but also with familial, social and career demands and future expectations, and possibly as well with financial security. I hope to provide some context, experience, judgment and empathy here. This shared decision-making generally requires a significant block of time, not a formulaic resolution. But present incentives tend to go counter to such discussions, especially EHR-based ones that are strongly biased toward billable procedures. And most importantly, this discussion is usually much more likely to be productive in the context of a vibrant, longstanding doctor-patient dynamic, compared to either a truncated or to an unfamiliar relationship.
And in Health On a more upbeat topic, I believe that it is important for all of us to maintain a healthy diet and exercise balance, so I try to incorporate some discussion and positive encouragement on this topic as part of my medical evaluations of patients. However, my approach to motivating patients to come up with a realistic plan that they can and will stick to varies widely from patient to patient. Again, a `one size fits all` glib comment about target weight rarely works, and the best strategies generally spring from a longstanding relationship with the patient. What has worked previously, and what has not? Does my patient prefer solo exercise, or more social workouts, like spinning? Are aerobic exercises best, or ones with less overt sweating, like yoga? Will a Fitbit encourage or frustrate? For joggers with lots of painful wear and tear, what about swimming? Or strength training? Do lifestyle considerations enter into the picture? Is my patient looking to potentially getting involved in a new relationship? Have life stressors derailed the balance, and if so, how can I re-motivate my patient to get going again, or to shift strategies? Does a patient do better with a pat on the back or a poke in the tush? All of these are critical factors to consider in attempting to optimize one’s health, among variables that we can control. So I am very concerned that collateral to more commoditized, process-driven care, our patients will be more likely to lapse into and retain a diet-exercise imbalance that will ultimately compromise both their quality of life and their longevity.
Scribes In his eloquent book The Digital Doctor, Robert Wachter makes a strong case for the use of scribes to facilitate EHR management. To paraphrase several sources, `the solution would be to take the doctors off the computer, put them at the bedside, and let the scribe do the transcription.` Indeed, the large number of doctors who now employ medical scribes to record the medical encounter into the EHR confirms the severity of the issue, and the potential utility of this solution. I agree that the scribe model may be both fine and appropriate for some specialties, but alas, not for mine. I can get at most 50% of my patients to allow a Yale resident in the same room to simply observe how I conduct an office visit, given the oftentimes confidential nature of the doctor-patient discussions, so I would expect that most of my patients would balk at the presence of a scribe. Also, I believe that it would often be very challenging for a scribe to properly identify, let alone extract the critical psychological or social observations that I would routinely make, based on longstanding relationships with my patients, that would determine individualized diagnosis and treatment in many cases. Once again, optimal care involves far more than data management and image analysis.
The Turing Test asks, in an Imitation Game, if a computer is sufficiently advanced so that an astute evaluator can no longer distinguish the machine from a human. I optimistically believe that continued advances in computer hardware and programming will provide ever-increasing complementary and synergistic utility to the practice of medicine. But the profession that I gladly entered, in which the laying on of hands and the heartfelt shared grief of a patient’s tears are vital signs as well, should never strive to pass Turing’s challenge.