Thursday, April 27, 2006

Doctoring the Doctor-Patient Relationship

Medicine is a documentation heavy field, and advances in technology have brought computerized documentation to our doorstep. While there are advantages to patient care in using a computerized system, there are also several disadvantages, most of which I won't go into here. What I want to illustrate is the stark contrast between pre- and post- digitalization of patient care, and it's effect on the doctor-patient relationship.

Scenario 1:
Patient comes to urgent care clinic to see physician (MD). MD browses chart, enters room, introduces self, and has a 15 minute conversation with patient to try to arrive at a diagnosis. MD does a physical exam, then discusses the diagnosis or need for further work-up with the patient. MD retreats to office after patient visit to document the visit and finish paperwork. Total time for interaction: 30 minutes. Time focused on patient: close to 30 minutes.

Fine, you may not have 30 minutes per patient in the HMO setting. Humor me - am trying to make a point here. :)

Scenario 2:
Patient comes to urgent care clinic to see MD. MD enters room, introduces self, and settles in front of computer. MD pulls up template and quickly browses the computerized chart. Same 15 minutes used in conversation, however, as patient explains symptoms and answers questions, MD typing away, staring at computer screen to ensure accurate keyboard entries. Or, if MD a proficient typist, MD trying to maintain some semblance of eye contact while fingers madly typing away on keyboard. MD does a physican exam, then rushes back to the computer to enter physical exam findings. MD discusses the diagnosis or need for further work-up with the patient. MD then enters the appropriate referrals and other requests into the computer. Total time for interaction: 30 minutes. Time focused on patient: 5-10 minutes. Time with computer: too much.

Common sense and documented research agree that patients consider bedside manner a very important skill; for some patients in certain situations, this may be possibly even more important that an extreme in medical expertise.

The advent of computerized charting brings concerns of a deterioration in bedside manner and further erosion of the patient-physician relationship. After all, once unacceptable things tend to become acceptable, even routine, after familiarization and practice. Even physicians who were once aware of the importance of good bedside manner may one day forget that staring at a screen while typing furiously is the antithesis of said manners. And what of the next generation, who will absorb computerized documentation as part of their training? Who will be there to remind them that it is not appropriate to sacrifice eye contact and associated nonverbal communication for the sake of technology, if their first introduction to clinical medicine involves residents and attendings modeling this behavior? How many more patients must we push away from the sterility of modern medicine before we realize something needs to change? Some physicians may look down upon "alternative" medicine, but what we can re-learn from them is excellent bedside manner - the ability to take a step back from all our technology and regain the skill to be present and use ourselves as part of the healing of our patients.


Anonymous A Nurse said...


4:28 PM  

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