Looking for the Human in Health Care

For all the problems of EHRs, they are here to stay, which means that somewhere in a visit between a patient and a physician a screen will be involved.  What is the best way to deal with this interruption in what otherwise is a basic human encounter?

Recent research suggests that patients often feel something is lost when the doctors pay more attention to the screen.  According to a recent article in JAMA Association Between Clinician Computer Use and Communication With Patients in Safety-Net Clinics by Neda Ratanawongsa, M.D., M.P.H. et al

“High computer use by clinicians in safety-net clinics was associated with lower patient satisfaction and observable communication differences. Although social rapport building can build trust and satisfaction, concurrent computer use may inhibit authentic engagement, and multitasking clinicians may miss openings for deeper connection with their patients.”

In fact eye contact is one way to assess the “authentic engagement” mentioned above.  A Wall Street Journal Article “ Is Your Doctor Getting Too Much Screen Time”, points to the lack of eye contact as “ the biggest problem with having to input information into a computer.”  Interestingly gender may affect eye contact between the patient and the doctor as Richard M. Frankel, Ph.D. explains in JAMA  “Female physicians will typically look up from what they are doing every 30 seconds or so, make eye contact to signal they are still actively engaged in the relationship, and return to typing. Male physicians tend to focus on the computer screen and rarely look up to signal engagement.”

There is an increasing understanding of the importance of non-verbal communication, including eye-contact, in the clinical encounter.  In fact eye contact can be used to measure the attention a physician and patient pay to each other during a visit, or the attention that either pay toward screens and EHRs.  This gets to the underlying issue of whether the doctor and patient are effectively communicating and understanding each other.

The question of the physicians eye gaze is studied in depth by Enid Montague, Ph.D .and Onur Asan, M.S. in a paper “Dynamic modeling of patient and physician eye gaze to understand the effects of electronic health records on doctor-patient communication and attention.”  They conclude” Physician gaze largely influences patient gaze in the primary encounter, which means that any intervention that influences physicians to focus on technology will subtract from patient-physician eye contact and any intervention to increase eye contact, or EHR information sharing, will likely need to be targeted to the physician. ”

To address this lack of focus on the patient Frankel recommends an approach he calls POISE in the JAMA editorial.  It stands for prepare, orient, information gathering, share, educate, debrief.  While this approach might makes sense in the clinical encounter, it unfortunately places the responsibility for system and cultural design on the end user.  Everything from the design and availability of examination room, to the choice of EHR product, to the length of a visit, in larger medical systems is determined by forces far away from the lonely physician at the end of the chain of command.  As scholarship in systems improvement and change management demonstrates again and again, problems that arise from systemic and cultural decisions are not easily solved solely by changes in the behavior and practices of an individual.

We agree with Dr. Elizabeth Toll in her 2012 JAMA Editorial “The Cost of Technology” that “Physicians and patients must speak loudly and clearly, with a unified voice, to address the dehumanizing trends in our profession and insist that the move toward technological reform not leave us with a nation devoid of physician healers. “  We also believe that to maintain the human element in medicine the solution needs to be systemic and cultural in scope.