Dr. Kristen Zarfos with a patient.

ctmirror.org, December 5, 2014

Not the best examining-room combo

By Christine Woodside and Dr. Kristen Zarfos


Researchers conducting dozens of studies in recent years have asked patients how they feel when their doctors stare at personal digital assistants or laptop computers instead of at them. Several of their studies in peer-reviewed journals concluded that technology in a doctor’s lap is good. We challenge this premise.

We think America is bumbling through the Dark Ages of examining-room technology.

Electronic medical records might seem inevitable, but using them properly still flummoxes practitioners. Only a quarter of 20,088 doctors surveyed this year for the Physicians Foundation said that this technology streamlines their workloads, and almost half of them complained that it hinders a decent bedside manner.

We are a patient and her doctor. We believe that doctors looking at screens can’t examine people. Doctors conducting a physical exam and asking questions now must very quickly turn to the keyboard. We don’t think they can do that in the examining room with any consistent success.

We have read through many of the peer-reviewed studies of this technology. We find evidence of a defeatist attitude about computers next to examining tables. If we had to invent a slogan for the current approach it would be: computers first, reasons for them second.

Let’s go back a few years. A study in the Journal of American Medical Information (in 2009) listed a “paucity of evidence” that these devices helped doctors treat patients. A 2010 report in Family Medicine claimed that although most patients perceive tablet computers positively, their attitudes differed: by age in how fast doctors could look up files, by race in worries the office was less personal, and by race and education level a feeling that the tablets took away privacy.

Newer studies suggest greater acceptance. In the Journal of Health Communication, a 2012 article said that patients who watched a brief presentation about why their doctors used PDAs or smartphones “increased measurable perceptions” of the devices.

We think that whether doctors explain to patients why they are holding PDAs or computers in their laps misses the actual problem — distraction.

Last winter, in the journal Academic Medicine, William Bynum, M.D., wrote that doctors “need to be more than automated medical kiosks.” But he didn’t say technology is a problem. He said doctors are the problem. Dr. Bynum claimed that medical leaders can “embrace and promote technological advancement while at the same time working to maintain the human connection that physicians have with their patients.”

We detect, again, an attitude of submission to technology companies. We say no. We think that—like the people who can’t concentrate on more than one task at a time—doctors expected to be caring practitioners and medical recorders will fail at one or the other of those tasks.

Doctors, nurses, physicians’ assistants, and other health workers have dealt with distractions forever, and when pressed, they will neglect record-keeping for the patients. A study by Scott R. Walter published in March in the journal BMJ Quality and Safety summarized the actions of 200 clinicians over 1,000 hours in Sydney, Australia. The authors wrote, “Documentation was generally given low priority in all groups, while the arrival of direct care tasks tended to be treated with high priority.” That doesn’t surprise us, but we point it out because we believe that computers have introduced even more distraction than previous record-keeping methods.

A 2013 study by computer experts Pushpa Kumarapeli and Simon De Lusignan in the Journal of the American Medical Information filmed 163 doctor-patient consultations using various computer-record systems. They found that 61 percent of the time, the doctor was directly interacting with the patient—15 percent actually examining the body, 25 percent using the computer, and 14 percent allowing the patient to look at the computer too. (They did not explain the remaining 7 percent of the examining time.) The conclusion of this study? That the record-keeping systems “should be designed to facilitate multi-tasking.”

The patient of us goes to a doctor whose office provides an online database of her health record. This record includes errors, even those pointed out previously. But the staff spends a fair amount of time entering data into this record, which takes away from their work with patients.

Dr. Suneel Dhand complained about the feeling of straddling two very different tasks in an essay last year for medpagetoday.com. “Now, instead of demands to see more patients in less time or increased bureaucracy from insurance companies, it is the time we are spending with computers that is increasingly taking us away from our patients.”

We agree. We have experienced these distractions from both sides of the exam table. Doctors stroking keys struggle against time that always gets away from them. Patients fear that their doctors care more about entering information into their devices than what the patients say.

Looking at a screen means one ignores the person sitting there. This seems as bad to us as the most stereotypical smug and distracted practitioner who interrupts a stuttering patient.

We both believe that time is a doctor’s most valuable commodity. Time with patients builds relationships. A doctor must earn trust by making eye contact and truly listening. A doctor learns a great deal just by watching patients’ responses to questions and listening to how they describe their problems. One can’t put a value on this.

If technology functions as efficiently as the manufacturers say, health offices and hospitals need scribes in every examining room. The skill of recording data and locating records is specialized. The doctor of us asked for a scribe at her previous job and was firmly rebuffed.

Scribes will undoubtedly increase the amount of information in a patient’s records. That will create new problems. Sometimes the overwhelming bulk of information can obscure the salient facts in a patient’s case.

As Abigail Zuger, M.D., wrote in an October 13 article in The New York Times, “Like computer servers everywhere, hospital servers store great masses of trivia mixed with valuable information and gross misinformation, all cut and pasted and endlessly reiterated. Even the best software is no match for the accumulation. When we need facts, we swoop over the surface like sea gulls over landfill, peck out what we can, and flap on.”

The doctor of us sits on a committee that will list important questions for breast care in an electronic medical record system — essentially, instructing the computer. Obviously a lot of care will go into this program. That does not change the basic problem we’re talking about. Physicians using electronic medical records say that the burden of inputting data clearly subtracts attention and time they could devote to patients.

Dozens more studies of the effects of technology on patients are out there or in progress. We say: ask the proper questions in these studies. Ask not how we can get patients to accept technology as if it were inevitable, like an asteroid plummeting to Earth. Ask whether we’re on the right track with this invasion of technology into the space of deepest human connection: the place where a doctor looks at a patient’s body and figures out whether he or she is sick.

Health and life are precious. They are also complex. They cannot fit into a size-4 time slot when a size-12 time slot is required.


About my co-author:

My longtime doctor and friend, Kristen A. Zarfos, M.D., FACS, is a surgeon specializing in breast and thyroid surgery at the Hospital of Central Connecticut. We thank Maryrose Keenan, MLS, for her help with research.

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