How to be Authentic Doctor 2: Look At The Patient
Do you believe that I have to mention this? I can’t believe it either but since the advent of the EMR, this seems to be an issue; a really big issue. Amazingly enough, you are there, as a doctor, to treat the patient and not the computer. You would think it was the other way around with all the bogus quality indicators, meaningful use baloney and pay-for-performance nonsense being stuffed down our throats, but don’t let the idiots who are now in charge of healthcare fool you. It really is about the patients.
I am on my third EMR system but I never let the computer enter the room with me. In other words, I preview the chart and then go in naked. Ok, I wear a stethoscope but that is it. Why? Because I want to look the person in the eye. Yes, you read that right, look at the patient.
Human beings are interesting animals. They kind of like to interact with other humans, which includes their doctor. Staring at the stupid computer screen interferes with that. Patients want to feel important. They want to feel listened to. When you look at the patient, you acknowledge that. You also listen better. When you turn to the EMR screen, you don’t. You may try to listen to them, but you are obviously searching the chart or typing in some information or prescribing a drug and guess what the patient is doing? He is either still talking or he is getting his own thoughts interrupted. This is not good care no matter how you rationalize it.
Maybe you are better than I am. Maybe you can bring your laptop into the room and really isolate the interview part of the visit by truly listening FULLY to the patient and not turning to the EMR, who, by the way, is screaming at you inside his or her head, “Look at me!” If you can pull this off then goody for you. It does not work for me. Most of you, however, are like me and will succumb to the temptation of turning to the damn computer too early. Sure, you will promise yourself you won’t. You will fight the pull as hard as you can and maybe you will succeed for the first few patients of the day. Unfortunately, your willpower will weaken and you will start cheating. Trust me, once that happens there is no going back for anyone else on your schedule. Been there, done that. Listen to me, don’t take the damn EMR into your room. If it is already there, shut it off.
Yes, we all need EMRs. Yes, with my way of not bringing the EMR into the room makes me leave at times to check on things but it also allows me space to think, time to look up stuff that I don’t know, and also stops the patient from interrupting me with more complaints that just popped into his or her head.
Lastly, if you would ask an old-time doctor whether looking at the patient was difficult to him then he would probably answer no and wonder whether you were an idiot. And he would do this the whole time while…..LOOKING at you.
Where I work now the nurses get a long list of symptoms, not just a chief complaint, on even the acute respiratory patients, as if they thought it was some kind of help and all I need to make a diagnosis. Of course I still get my own history, but it makes me so much more aware of how much less I would really know about the situation if I didn’t catch all the nuances of phrasing, tone of voice, and what meaning and importance the patient ascribes to each symptom. I just can’t imagine making a diagnosis without all that, never mind convincing the patient of it and making them feel even briefly cared for. How could I do it while checking boxes like the list the nurse had given me that gave me no idea usually what was going on?
I compromise when I’m at my weekly primary-care clinic: I print out the visit sheet (on which the nurse has listed meds & vital signs and chief complaint) and walk into the exam room with it. Before doing so I look up when the last Pap smear/HgbA1C/CBC was and make a note if it’s due; while visiting with the patient I take notes on the history and note what needs renewing, labs to order etc. I put a square by each of those and at the end of the visit I do all that stuff on the computer, including faxing scripts to the pharmacy. Elapsed time almost exactly the same as for the old way, but the faxes are a big hit and the writing more legible. AND I LOOK AT THE PATIENT.
“Yes, we all need EMRs.”
Do we? I’m more and more convinced our decision to stay with paper is the right one. It’s certainly a big practice builder, attracting patients who want to maintain some privacy for their medical history.
I don’t have to worry about this crap any more. After 37 years of general practice and having just started EMR in our group practice, I opted out and retired. I couldn’t be happier.
No, you have to mention it I suppose. It can be a bad habit of mine as well. I had a patient call me on it just today, and I see your post five minutes later.
I’ve been using an antiquated EMR since ’95. As a psychiatrist, I spend a lot more time with patients than most physicians and even most other psychiatrists. The EMR is invaluable as a record keeping device, I don’t bother with quality indicators, and I use it when doing med checks but not when I’m engaged in 50 min psychotherapy.
That said, I believe patients respond positively to my use of computer in our meetings, and I find that I am still able to connect with them in a meaningful way. I believe it is easier since I “grew up” i.e. learned medicine in the pen and paper world and then transferred my “bedside” approach in the 90s.
Blaming the EMR is, I think, a bit off the mark. We need to blame the whole system that is demanding faster, quicker and cheaper — and this is what takes our focus away from the people we treat.
Do other health professions have similar issues? When I think about dentists, I find I am never alone in the chair. There is always someone in there with the dentist – taking notes, sucking water out of my mouth, etc. What if we transferred this to medicine? What if the MA were to join the doctor in the room – as EHR scribe? I know medical assistants are busy too; nor are they cheap, but if they could be used to relieve some of the administrative burden from physicians, wouldn’t that allow doctors to be doctors again? (Please bear in mind, I’m not advocating. I don’t even know if it would work. I’m only offering a suggestion. Would love to hear if it worked.)
I have a 32 inch screen mounted on the wall and the patient and I look at their record together. It pulls them into their health care and holds them more accountable. Great teaching tool. Look at trends together. B/P. Cholesterol. Easier to enforce preventative health care needs.
When I was still working as an RN in a small community hospital with a very small family practice residency program the residents used to come on the floor, write their orders and THEN go see the patient. I always thought that to be a little backwards and so did their instructor. He would ask them why they ordered such and such when the patient obviously was better and didn’t need that test. Wonder how many of them still do order first and see second. Kind of like doing CPR on someone whose leads fell off.
Agree. Agree. Agree.
I pride myself on my connection to my patients and to listening.
A few of the last specialists I have encountered did not look at me at all during most of our meeting. In one I asked him to.
Dave