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My Doctor Is a Computer!

There was no mistake, but a bad thing has happened.  Despite the best efforts of the doctors, Bob’s wife is very sick.  Due to a rare side effect of treatment, her liver is failing.  Bob believes this could have been prevented. He is very mad.

“When we go to see the doctor, he stares at the computer,” says Bob. “He does not look at us.  Most of the time, the doctor is not even listening to us. He just sits there typing at the keyboard, gaping at the screen.  If he had been listening when my wife talked about the pain, then he would have stopped the drug.  Then her liver would be fine. She would be OK.  All you doctors have become nothing but computers.”

Now here it gets interesting.  After I listened carefully to Bob and sat with him at his wife’s bedside, I decided to check “the computer.”  There in the doctor’s records I saw a long discussion and analysis of the problem with her liver. Quite opposite of ignoring her, her doctor had listened, had changed therapy and was watching her liver carefully.  Sadly, despite the change, her liver had gotten worse. The problem therefore, was not that the doctor was not listening.  He definitely was.  The problem was that the computer had stopped him from communicating.

It is strange to think that a system of information and data exchange, which allows you to communicate with anyone around the entire world, interferers with connecting to the person right in front of you.  We see it constantly as cell phones, Ipads, computers and even that “old” obstructer the television, get between us.  At the time we need to communicate most desperately, electronics can block that most human connection of all, the physician – patient relationship.

Let us be clear.  Multitasking is a fallacy.  We can only do one thing at a time.  We cannot drive and text.  We cannot talk on a cell phone and listen to our mates.  We cannot watch a game on TV and discuss finance with our partners.  Most importantly, we cannot focus fully on a patient and a computer at the same time.

Now, I am 100% committed to full computerization of the medical community and exam room.  The future of quality, medical safety, and cost containment can only come from full implementation of Electronic Medical Records (EMRs) with system wide analysis and the assistance of artificial intelligence.  However, right now is a tough time.  We need to figure out the new social mores’ and workflows, which will allow physicians to communicate with patients and with the electronic world.

Therefore, both physicians and patients need to learn new habits and establish slightly different norms for the doctor visit.  Patients must understand that for moments the doctor will look at the computer instead of directly at them, and not be offended.  Both doctors and patients should turn off their cell phones.  Doctors need to take time during each visit to look patients in the eye, instead of ogling the monitor.   Exam rooms should be set up to make this easy. It is one thing to type information (smoking history, dates they of medicines, type of surgery…) and another to ask tough personal questions while absorbed in a monitor. Doctors must never teach or give advice while at the keyboard. We must turn, see and touch our patients.

As Bob’s experience shows, even if a physician is doing the correct thing and paying close attention, the patient sees only an uncaring man staring at a screen.  The direct contact of the physician – patient experience is still vital.  Medicine is about people helping people and the cold interaction of the supermarket checkout line, will not suffice.

James C. Salwitz, MD is a Medical Oncologist in private practice for 25 years, and a Clinical Professor at Robert Wood Johnson Medical School. He frequently lectures at the Medical School and in the community on topics related to cancer care, Hospice and Palliative Medicine. Dr. Salwitz blogs at Sunrise Rounds in order to help provide an understanding of cancer.

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SimonConnect Physical HealthAshleyBobbyGDeterminedMD Recent comment authors
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Simon
Guest

I hope your computer is more reliable than mine!

Connect Physical Health
Guest

Interesting article and quite the conversation, too.

DeterminedMD
Guest
DeterminedMD

Again, the guy attacks my argument and just validates it by the time he finishes his retort. I believe he is just a front man for forcing IT on health care without understanding consequences.

Hey Mr G, just because I dislike the overall tone of what the Net is doing to human communication does not mean I am a pure Luddite. Besides, if I listen to you, then I would make the mistake of validating your agenda. Getting all dissent to just retire and vanish. Just like politics of usual seems to try these days.

BobbyG
Guest

“forcing IT on health care without understanding consequences.”

Keep digging.

DeterminedMD
Guest
DeterminedMD

Just for the record, your position on the value of Twitter, and do you think it has any place in health care?

BobbyG
Guest

1. I have a twitter account, but I rarely use it. I’m too busy to be constantly interrupted, mostly for trivial stuff. Pear Analytics estimates that twitter traffic is nearly 90% blather.

In general, I find the whole “texting” thing a step backward. SNL even once spoofed it

2. No.

DeterminedMD
Guest
DeterminedMD

Thank you for your straightforward reply.

southern doc
Guest
southern doc

“I see you use the internet.”

And how many of us are using the Internet because the government requires us to do so? How many of us are using the Internet because it’s expensive and slow, but allows data to be collected that may be useful in 10-20 years?

Or are we using the Internet because the technology was allowed to naturally develop to a point where its utility became readily apparent?

BobbyG
Guest

Yeah, it was a weak analogy. But, we use the internet because the government — DARPA, specifically — created it, via a set of standards. Had that not been the case, we might have a dozen proprietary internets, all silo’ed and expensive (though, some people would like to see that happen). “allows data to be collected that may be useful in 10-20 years?” I have to disagree. While the larger benefit — CER — will indeed take years to accrue (and will be fraught with difficulty), the num/denom structured data measures in the MU specs will be useful from the… Read more »

BobbyG
Guest

DeterminedMD says: @April 12, 2012 at 7:30 pm “The world is gray, yet those here who want to keep it black and white only do yourselves disfavor. The physicians who make poor choices are not the majority, and trying to insist we submit to IT fully and completely will not prevail. Putting everyone in an electronic system only creates at least mischief by government, but mostly nefarious endpoints by entrenched leadership. Obama is, in the end, just a power addicted rock star who has no clue to the concepts of humility and honesty. Neither did Bush Jr in office.” __… Read more »

MD as HELL
Guest
MD as HELL

SOAP notes were adopted, not inflicted.

BobbyG
Guest

Links? (I can’t prove it one way or another; and. “inflicted” is principally just a partisan POV).

How about a stroll down memory lane?

“PROMIS”

http://www.campwoodsw.com/mentorwizard/PROMISHistory.pdf

BobbyG
Guest

MD as HELL says:
April 12, 2012 at 3:54 pm
Bobby,
This is brilliant. This is transformative. Use it. Buy it. Bet your life on it.
What do you need a doctor for?
___

Right.

MD as HELL
Guest
MD as HELL

That’s it? “Right.” Really? Replacing doctors with computers and algoriths is like replacing German Shepherds and Bloodhouhds with robots and cameras. Neither is a good idea. Neither the skills nor the special senses of either in real time can be replaced by machines. “In real time” is the key denominator. In an emergency e.g. a bad car wreck, I can collect most relevant information in a moment. Simultaineously I can direct nursing interventions, lab studies,and imaging while intubating and paralyzing the patient (if needed) for airway protection. I can then move on to chest tubes, central lines, controlling bleeding. All… Read more »

BobbyG
Guest

“Someone please tell me why you want to force doctors to do clerical computer entry work?”
__

I certainly don’t. You proffer a vivid straw man scenario to conflate the core issue, as a way of trying to deflect it.

MD as HELL
Guest
MD as HELL

“Straw man scenario”…nothing “straw man” about it. It happens all the time. I am trying to deflect nothing. I am trying to kill it dead. I’ll leave the conflating to you.

BobbyG
Guest

OK, as I reflect on this proffer…

Are you SERIOUSLY trying to argue to me that your Heroic, Manly, Beneficent ER Derring-do exempts you legally from having to somehow document (even by proxy) your myriad STAT actions and decisions?

If you are in fact who you say you are.

I can pretty quickly find out legally acceptable routine ER procedure. So let’s cut the crap, OK?

MD as HELL
Guest
MD as HELL

Of course I have to document. It is the only way to get paid. It is for the benefit of the patient and his care, no and in the future. But it is not done in real time. There are different ways to achieve documentation. Directly interfacing with the computer is the least efficient and least productive. I do not care what you want to put in the computer. I do protest being the secretary. I do protest you forcing me to do data entry. I do protest CPOE. I am trying to illustrate the relative importance of the computer.… Read more »

DeterminedMD
Guest
DeterminedMD

Pay attention to the defense mechanisms of those who just automatically dismiss and/or demean physician commenters.

BobbyG
Guest

Pay attention to the defense mechanisms of those who just automatically dismiss and/or demean non-physician commenters.

DeterminedMD
Guest
DeterminedMD

Thanks for your validating retorts. Why others attempt to dialogue with your insulting comments you try to then rationalize or minimize, that’s their choice.

Here’s an idea, little man, if you do not like what I write, maybe, ignore it?

You write like the class clown sometimes.

Believe me, I try to ignore you as muchas possible. I’d love to hear some of these alleged physician colleagues you claim as peers comment how you conduct yourself in their offices.

BobbyG
Guest
BobbyG

Right.

BobbyG
Guest
BobbyG

Anything substantive to say about the Weeds’ work? In lieu of your indignation with me?

DeterminedMD
Guest
DeterminedMD

The world is gray, yet those here who want to keep it black and white only do yourselves disfavor. The physicians who make poor choices are not the majority, and trying to insist we submit to IT fully and completely will not prevail. Putting everyone in an electronic system only creates at least mischief by government, but mostly nefarious endpoints by entrenched leadership. Obama is, in the end, just a power addicted rock star who has no clue to the concepts of humility and honesty. Neither did Bush Jr in office.

DeterminedMD
Guest
DeterminedMD

Just curious, do plumbers allow the internet to drive their profession? How about lawyers? Auto mechanics? And yet doctors continue to just bend over and take it where the sun don’t shine. Empathy and compassion, enjoy being stabbed over and over with them when used as a weapon against us? It is ok to be harsh and rude and still be a doctor. ‘Cause we have few allies of late, after all, once nurses found out they could be a cheap alternative, everyone has been lining up for our privileges and abilities without the training. The story of Passover is… Read more »

BobbyG
Guest

Retire.

DeterminedMD
Guest
DeterminedMD

Suck an egg.

BobbyG
Guest

“A culture of denial subverts the health care system from its foundation.The foundation—the basis for deciding what care each patient individually needs—is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new, secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information. Electronic information tools are now widely discussed, but the tools depend on standards of care that are still widely ignored. The necessary standards for managing clinical information are analogous to accounting standards… Read more »

Dr. Mike
Guest
Dr. Mike

“This meticulous matching process is feasible only with software tools…the tools are trustworthy only when their design and use conform to rigorous standards of care for managing clinical information…Without the necessary standards and tools, the matching process is fatally compromised.” i.e. not yet ready for prime time. Where are these software tools? Have the “rigorous standards” been field tested and proven superior? Is there a real world example? What do EHRs, as currently conceived, have to do with any of this? I say we have a history in this country of adopting promising technology well before its time and clinging… Read more »

MD as HELL
Guest
MD as HELL

Bobby,

This is brilliant. This is transformative. Use it. Buy it. Bet your life on it.

What do you need a doctor for?

Jim Salwitz
Guest

I would agree. The purpose of IT should be to augment the physician. We will always need the human interface to actually “touch” each patient.
jcs

DeterminedMD
Guest
DeterminedMD

Not if we let the advocates of the internet continue to drive the debate. The lose of healthy self this medium has created will terminally alter the physician-patient interaction to a point where doctors will be sued because they foolishly agreed to treat by a screen.

Ashley
Guest

I think you pinpointed something really great in this post. I understand that technologocial advances are a continually changing and greatly impacting devices in our healthcare system, but there still needs to be the physical role of the doctor. I see many websites offering online diagnosis now and I just wonder what direction we will go into next; if we were all doctors it would be a diffferent story; or if the computer was a living being but neither of those things will ever be true. Therefore, I believe in leaving the diagnosis to the doctors but imrpoving technology to… Read more »

BobbyG
Guest

“I believe in leaving the diagnosis to the doctors but imrpoving technology to help assist them in doing their jobs.” __ Yes, and the very point of the Weeds’ book “Medicine in Denial.” “A culture of denial subverts the health care system from its foundation.The foundation—the basis for deciding what care each patient individually needs—is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new, secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical… Read more »

BobbyG
Guest

As an addendum, yeah, ok, I KNOW that the billing imperative continues to drive too much of HIT.

Jim Salwitz
Guest

There are several ways by which it will help us gain control. First, by measuring, defining and actualizing quality we will be able to push back against gov’t and insurers and stop playing the stupid, inefficient and frequently wrong pre-cert game. Next, by being able to exactly define our costs at the same time we guarentee quality we will be able to take on risk. Instead of begging for each dollar for each visit we will be able to accept lump sum payment for care (ie take a single payment for a specific pt with a disease or accept risk… Read more »

southern doc
Guest
southern doc

Sorry, I don’t see how EMRs will allow docs to “control the data.” Isn’t the whole point that EMRs will give CMS/insurers immediate access to every dotted i and crossed t in the medical record?

What seems more likely is that we move to having real-time authorization of every single lab test, procedure, office visit, script, with “clinical decision making” guidelines that will take an act of God to override.

Jim Salwitz
Guest

Fascinating. The hope and goal of putting in place a disruptive technology, is that the technology will be transformative . There can be no doubt that IT has already morfed other industries. If the government or other players think that global IT will simply codify the present, they do not understand the power of the technology being released. I.E. Facebook is not simply about college students sharing pictures, but is transforming major parts of business and society. As a physician I see the potential as empowering my profession and thereby globaling improving healthcare (and perhaps cleaning up the mess).

MD as HELL
Guest
MD as HELL

It all depends on your point of view, does it not? The world lives just fine without being on Facebook, a fact you cannot possibly believe if you are inside Facebook. For you who have been assimilated it has been transformative, but that is not by definition a “good” thing. It is just “a” thing. For us not assimilated it is a minor amusement and a threat to privacy. You see it as empowering our profession and globally improving healthcare and cleaning up some mess. I see it as a technology and a mentality maliciously invading a relationship and a… Read more »

BobbyG
Guest

Some free Lawrence Weed for cheapskates: __ LJ: Dr Weed, you have had an amazing career implementing a needed change in how patient data is handled through the POMR. Today, you outlined another major change that needs to be incorporated if the practice of medicine is to be improved. On the basis of your experience as an innovator, and knowing what you know today about medical education and the practice of medicine, are you optimistic such changes will be forthcoming? LW: Based on what I know about all the vested interests in the present medical education system and in the… Read more »

Jim Salwitz
Guest

Well said.
The future is a painful not far away.
jcs