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In Practice

Doctors, patients, and computer screens

Dan Page for The Boston Globe

A woman in her 60s comes in for her annual physical. She feels fine. Still, there are things she’s eager to discuss with me. She’s terrified she’ll again come down with the illness that put her in the hospital a couple of years ago. Her kids are an ongoing source of stress.

I turn my chair away from the large computer monitor on my desk. I direct my full attention toward my patient. I think how lucky I am to have a job that involves making intimate connection with other human beings. I think, as my patient confides in me her fears about her health and her worries about her son’s addiction and her daughter’s shaky marriage: This is why I became a doctor.


Suddenly, I’m aware of the time. Twenty minutes into a 30-minute visit and I’ve entered nothing into the computer! If I don’t start typing I’ll fall hopelessly behind and keep other patients waiting. I must click boxes to confirm the patient’s medications; refill her prescriptions; record the flu shot she had at a local pharmacy; document that I recommended a shingles vaccine; generate lab slips and a form for her Pap smear; bill the patient for her visit; type a note.

As I tap my way through screen after screen, straining to maintain contact with my patient out of the corner of one eye, I think: This is not why I became a doctor.

I recall discussions years ago about whether computers could ever replace physicians. Since the 1970s, programmers have tried to devise systems that deduce a diagnosis when fed clinical data. But computers can’t account for body language and the many other ambiguities that make medicine more art than science. Thus far, doctors’ jobs aren’t threatened by automation.

Nowadays, though, we ask ourselves, half-jokingly, whether computers will replace patients. I’ve heard doctors who are discouraged by the amount of time we spend at the keyboard comment that we’re “getting very good at treating . . . computers.” Some call this state of affairs “death by a thousand clicks.” The computer erodes the physician-patient relationship and contributes to dissatisfaction of both doctors and patients.


Or does it?

Depressed by all that clicking, and yearning for the days of (often illegible) notes and prescriptions handwritten in elegant fountain pen, I sought to cheer myself up by speaking with three physicians, leaders in medical information technology, who take a decidedly more optimistic view of the computer’s role in medicine than I do.

One is Dr. Tom Delbanco, professor of general medicine and primary care at Harvard Medical School and cofounder, with Jan Walker, RN, MBA, of OpenNotes, an initiative that gives patients ready access to their medical records. Though not dependent on computers — Delbanco has been mailing patients his records of their visits for decades — digitization makes the sharing of information between patients and doctors easier. Delbanco sees the computer not as a wedge but as a means of knocking down what he calls the “invisible wall” between doctors and patients.

Delbanco and his colleagues recently reported that among 20,000 patients invited to view their medical records online, most said that such access helped them understand their medical care better, made them more likely to take medication as prescribed, and made them feel more in control of their health. Interestingly, though doctors often express concern that patients might misconstrue or be alarmed by their unfiltered medical records, doctors surveyed by Delbanco’s team found this not to be the case.


Delbanco told me he envisions a not too distant future in which computers enable physicians and patients to write notes jointly and share tasks such as setting health goals, completing forms, and even ordering tests. He’d be happy to see patients posting their medical records on social media if they chose, soliciting opinions from far beyond their doctor’s offices.

Dr. John Halamka, chief information officer at Beth Israel Deaconess Medical Center, shares this vision. He imagines digital medical records, ideally, as a kind of “Wikipedia entry of the patient’s experience” — collaboratively created and continually updated by the patient and his or her caregivers. Halamka is mindful of the challenges of digitization, including balancing privacy and transparency and ensuring that those who design computer systems work closely with the clinicians and patients who actually use them (this does not always happen).

Halamka is not so worried about computers causing loss of eye contact between patients and doctors. He points out that we can switch from desktop monitors to small screens, such as tablets, that can be shared across a desk or viewed side by side. Halamka is also enthusiastic about new technology, such as Google Glass, which would allow a doctor to look at the patient and data on a screen simultaneously. “We’re still in an awkward position,” Halamka feels, regarding information technology and medicine, “but we’re on the right trajectory.”


Dr. David Blumenthal, who researches health and social policy as president of the Commonwealth Fund and who served as National Coordinator for Health Information Technology from 2009-2011, thinks some of the awkwardness physicians like me experience comes from the fact that “technology is good enough to record the information and to improve care, but not good enough to make daily work easy for clinicians.” In other words, computers, at this point, are creating more drudgery than Jetsons-like efficiency for doctors — but that will change.

Blumenthal believes that “given its huge public health, research, safety and quality advantages, the digitization of health information is inevitable,” and he predicts that voice recognition and systems that enable patients and medical assistants to enter more data will transfer much of physicians’ digital burden.

Blumenthal also implied something that had occurred to me but that I’d preferred not to think about: part of my problem with computers is my age. Though I’m no Luddite, my younger colleagues are less troubled by screens than I am.

“For physicians of a certain generation,” Blumenthal told me tactfully, the current status of computers in medicine is “a painful interlude in an important historic process.”

Dr. Suzanne Koven, a primary care internist at Massachusetts General Hospital, can be reached at inpracticemd
. Read her blog on www.boston.com/health.