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A 1684 engraving by Robert White depicts England’s King William II performing “the royal touch,” a laying on of hands that was purported to cure scrofula, a form of tuberculosis. In the picture, the patient is kneeling, with the king’s hands touching the affected area. Aside from the fact that the procedure had no basis in science and no effect on a cure, it does illustrate a timeless principle of medical care: the importance of direct contact in the process of providing care.
The tradition of direct (skin to skin) contact can be found in the 19th-century practice of listening to the heart and lungs by placing one’s ear directly on the patient’s chest. In 1816, René Laennec, a French physician, was asked to examine a young woman with signs of heart disease. A devout Catholic, Laennec was embarrassed by the prospect of putting his ear to the young woman’s exposed chest to examine her. Instead, he rolled a piece of paper into a tube and listened through it; thus, the stethoscope was invented. More important for our purposes, the stethoscope (technology) came to mediate the relationship between physicians and their patients.
Today, there are many ways in which technology comes into play in the examination room. We routinely measure blood pressure and examine the eyes, ears, nose, and throat while seamlessly integrating talk and technology into the visit. The latest technological innovation to affect the physician-patient relationship is the examination room computer. The promise of examination room computing is safer, more efficient, and effective care.1 While this promise has been realized to some extent (eg, medication errors have been reduced), many authors, including Ratanawongsa et al2 in this issue of JAMA Internal Medicine, have drawn attention to the potential downsides of examination room computing as a disruptive innovation with unanticipated negative consequences.
A dramatic example can be seen in a picture drawn by a 7-year-old patient published in JAMA.3 It shows the patient sitting on the examination table with a nurse next to her and her mother observing. Unfortunately, the physician is positioned with his back to the patient, typing on his computer. The author suggests that the demands of examination room computing can detract from the physician-patient relationship and that the human cost of technology needs to be factored into the care process. More important, as Ratanawongsa et al2 assert, the negative effects of examination room computing may be especially challenging for patients with low health literacy.
Research and common sense suggest that the more time physicians spend interacting with the computer screen, the less time they will have for direct eye contact with patients. Some patterns of examination room computing are habitual. We have found wide variation in examination room computer use: some physicians spend more than 80% of the visit time interacting directly with the patient, while others spend more than 80% of the visit time interacting with the computer screen.4 And, as Ratanawongsa et al and others have found, the greater the amount of screen time, the less positive a patient’s experience is likely to be. We have also found sex differences in how the computer is used. 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.
Habits aside, there is another problem that makes examination room computer use challenging: the physical placement of the computer. While the sphygmomanometer, otoscope, and opthalmoscope are in standard locations in the examination room, the computer can be literally anywhere. Unfortunately, in most hardwired set-ups, the computer is in a corner of the room where the physician’s back is to the patient.5 Even more unfortunately, there are, at present, no national standards for computer placement as there are in other industries (eg, aviation).
The good news is that there is growing interest in and scholarship on this topic.6-8 Based on a review of the literature and my own research, I offer the mnemonic POISED (prepare, orient, information gathering, share, educate, debrief) as a memory aid for developing and reinforcing good computer use habits.
In busy primary care practices, the time-honored habit of reviewing the patient’s medical record before entering the examination room may be overlooked and several precious minutes of face-to-face time may be spent silently reviewing the medical record with the patient in the examination room. This method is inefficient and can sometimes prove embarrassing when a patient reminds the physician of why he or she is there (eg, “You told me to schedule a follow-up for my diabetes care.”). Preparation for the visit is key to efficiency and improved patient experience and trust.
One best practice is to spend the first 1 to 2 minutes of the visit engaged in dialogue with the patient without using the computer at all. Once a welcoming atmosphere has been established, partnership statements such as, “I’m going to be using the computer from time to help me keep track of things” will alert the patient of your intent and rationale for using the computer. In a study of medical malpractice and communication, orientation statements proved to be protective while their absence was associated with a history of malpractice.9
Recent scholarship suggests that some parts of the encounter should be centered on the physician and others should be centered on the patient or physician-patient relationship.10 Using the computer during information-gathering segments of the visit is both appropriate and expected by patients. Although this process may seem counterintuitive, if you do not enter information into the computer from time to time, you risk patients questioning how seriously you take their concerns. Timing is everything.
The computer is a wonderful source of information and patients appreciate it when they feel like they are partners in the care process. Turning the computer screen so patients can see what you are typing has the double benefit of partnership and serves as a way to check that what is being typed is what was said or meant.
The computer screen is also useful as a teaching aid. With a click of the mouse, information such as a patient’s weight, blood pressure, and blood glucose measurements can be shown as a histogram and become the basis for a conversation either reinforcing good health habits or talking about how to improve them.
Do not take for granted that instructions to patients are clear and perfectly understood. Examination room computers provide the perfect opportunity to use a “teach back” or a “talk back” format to assess the degree to which recommendations are understood.
Being POISED for examination room computer use need not cost additional visit time. Used well, just the opposite is true. Medicine is fundamentally a human enterprise that is still practiced one conversation at a time. The study by Ratanawongsa et al2 reminds us that our most vulnerable patients may be at even greater risk than others when a disproportionate amount of a physician’s time is spent interacting with the computer screen and not with the patient. It is said that technology is neither good nor bad, but it is not neutral. Our challenge is to find the best ways to incorporate computers in the examination room without losing the heart and soul of medicine: the physician-patient relationship.
Corresponding Author: Richard M. Frankel, PhD, Indiana University School of Medicine, 1481 W 10th St, Indianapolis, IN 46202 (firstname.lastname@example.org).
Published Online: November 30, 2015. doi:10.1001/jamainternmed.2015.6559.
Conflict of Interest Disclosures: None reported.
Frankel RM. Computers in the Examination Room. JAMA Intern Med. 2016;176(1):128–129. doi:10.1001/jamainternmed.2015.6559
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