Like the mail carrier or the milkman of yore, the doctor makes rounds every day in the hospital. If it’s an academic institution, a bevy of medical students, interns, and residents accompany an attending physician from room to room, checking up on the patient, doing a daily physical exam, reviewing the latest test results, and highlighting the relevant teaching points. That’s been the mainstay of medical education, and that’s how my colleagues and I were taught to train the next generation of doctors.
Alas, this image would be true today only if a computer terminal were plunked in the bed instead of a patient. A new study in the Journal of General Internal Medicine confirms what any physician or patient could tell you: Doctors spend more time with computers than they do with patients. In fact, computers handily beat out patients: medical interns spent 40 percent of their day with a computer compared with 12 percent of their day with actual living, breathing patients. (Discussing cases with other health care professionals and educational activities were the other main activities of the day.)
In similar studies from 10–15 years ago, doctors clocked in about 20 percent of their time with patients. Although the studies are not direct comparisons, this observed decrease in face time between doctors and patients mirrors the experience of most participants in our health care system that is increasingly dominated by the electronic medical record (EMR).
This particular study examined only one subgroup of doctors (medical interns on an inpatient ward), but this dominance of computer time over patient time is pervasive in most areas of medicine. Nurses are practically chained to their computers these days. A typical outpatient office visit today consists of a doctor focused directly at a screen, and a patient waiting, ahem, patiently, while the doctor thrashes it out with the computer, furiously typing notes, orders, and prescriptions, occasionally whacking the side of the computer in frustration.
How did we get here? Medicine started out as an entirely hands-on, one-on-one profession. It wasn’t so long ago that the listening to the story and the physical exam were our only diagnostic—and therapeutic—tools. We are all grateful that there is much more to offer now, and no one wants to practice—or experience—medicine without antibiotics, chemotherapy, CT scans, or general anesthesia.
But each technological step forward seems to have had the effect of pulling the doctor one step further away from the patient. Rene Laennec’s stethoscope yanked the doctor’s ear off the patient’s chest in 1861, and it seems like we’ve been backing away ever since.
The question is whether this really needs to be the case. Does technology, de facto, have to pull caregivers away from their patients? The answer, of course, is no. Technology itself is neither good nor bad, but how it is integrated into medicine is the crucial point.
For many doctors, nurses, and patients, the experience of technology today—particularly the EMR—makes it feel as though technology is front and center while actual medical care is secondary. The expansion of the EMR has taken us to the point that caregivers hardly need to see a patient at all; the practice of medicine can be entirely virtual. Abraham Verghese has written poignantly about hospitalized patients functioning as “icons” for the doctors who remain hunkered down with their PCs.
The observation that direct interaction with patients has dropped precipitously in the past decade is additionally dispiriting from the perspective of the education of future doctors.
It was a brazen revolution in the 1890s when Sir William Osler pulled medical students out of the lecture hall and into the ward, with the startling idea that students needed to learn medicine with actual patients. But our technologic march has steadily sapped this Oslerian ideal, and our trainees today are missing out on many of the finer points of medicine. Despite the impressive leaps forward in simulation technology, you simply cannot learn the subtleties of assessing a wound, palpating a spleen, asking the right questions, navigating a patient’s fears, engendering trust, without actually being with patients.
And for patients, medical care has become an increasingly isolating experience, as their caregivers seem more beholden to technologies than to their illness, which is most certainly not virtual.
We need to rethink the role of technology in medicine, especially the EMR. The new mantra of “patient-centered care” needs to apply equally to our computerized systems. With each new iteration of the EMR, we need to ask ourselves how patients are benefiting, as opposed to whether we are merely satisfying administrative documentation mandates. The EMR needs to exist in service to patient care, not simply as an end in itself.
In elementary school, we once watched a movie that described planet Earth from the perspective of interplanetary researchers. After careful observation, the researchers concluded that Earthlings were metal boxes with four wheels, since all they saw in the streets were automobiles. If those researchers were studying our medical system today, they’d probably deduce that the patient was a 27-inch glowing screen, duly lavished with the best in patient-centered care.