Lown, Beth A. MD; Rodriguez, Dayron
Dr. Lown is associate professor of medicine, Harvard Medical School, Boston, Massachusetts, medical director, Schwartz Center for Compassionate Healthcare, Boston, Massachusetts, and director of faculty development and fellowships in medical education, Mount Auburn Hospital, Cambridge, Massachusetts.
Mr. Rodriguez is an MD–MPH candidate, Harvard Medical School and Harvard School of Public Health, Boston, Massachusetts.
Correspondence should be addressed to Dr. Lown, Schwartz Center for Compassionate Healthcare, 205 Portland Street, Boston, MA 02114; telephone: (617) 724-4746; fax: (617) 643-6123; e-mail: firstname.lastname@example.org.
The media through which we communicate shape how we think, how we act, and who we are. Electronic health records (EHRs) may promote more effective, efficient, coordinated, safer care. Research is emerging, but more is needed to assess the effect of EHRs on communication, relationships, patients' trust, adherence, and health outcomes.
The authors posit that EHRs introduce a “third party” into exam room interactions that competes with the patient for clinicians' attention, affects clinicians' capacity to be fully present, and alters the nature of communication, relationships, and physicians' sense of professional role. Screen-driven communication inhibits patients' narratives and diminishes clinicians' responses to patients' cues about psychosocial issues and emotional concerns. Students, trainees, and clinicians can, however, learn to integrate EHRs into triadic exam room interactions to facilitate information sharing and shared decision making.
Student exposure to EHRs is currently limited. Educators and researchers should implement curricula and assessment tools to help learners integrate EHRs into clinical interactions in ways that foster, rather than diminish, communication and relationships. Further, educators must prioritize the teaching and modeling of self-awareness and self-calibration, mindful presence, and compassion within such curricula to prevent these important qualities and skills from being lost in translation in the digital era.
Effective patient–physician communication is essential for high-quality care. Medical students learn structured ways of interviewing patients and communicating through written notes early in medical school. These communicative structures contribute to their enculturation as physicians, influence their understanding of the patient–physician relationship, and shape how they interact, communicate, interpret patients' problems, think about patient care, and understand their roles as physicians. As electronic health records (EHRs) become increasingly common components of 21st-century health care delivery systems, these technologies will inevitably shape communication and relationships.
EHRs and other forms of health information technology hold the promise of enabling users to provide more effective, more efficient, more coordinated, and safer care. Recent evidence suggests that some of these benefits are beginning to emerge, but provider dissatisfaction with EHRs remains problematic, and patients' reactions to EHRs are mixed.1,2 EHRs introduce a “third party” into exam room interactions that reshapes the patient–physician encounter, alters the patient's narrative, and diverts physicians' attention away from the patient. This diminishes the patient-centeredness of interactions, which in turn affects the patient–physician relationship. As Marshall McLuhan3 said nearly 50 years ago, “The medium is the message.” It changes how we think, how we act, and who we are. Through the new medium of EHRs, will compassionate, effective, patient-centered care get lost in translation? What role can the community of medical educators and researchers play in preserving learners' caring attitudes and teaching the skills they need to harness the power of health information technology appropriately?
Students begin the transformation to physician with their first patient interview. They don their new white coats filled with a mixture of excitement and dread, many feeling like impostors. When they begin, their eyes are glued on the patient. They follow the threads of the patient's story, winding down the many paths of personal loss and sorrow, accepting unfiltered how the patient's associations explain the cause of symptoms. Here is an example of a note written by a first-year medical student:
Mr. A is a 70-year-old school cafeteria worker who came to the hospital because he was feeling sharp chest pain and lightheadedness. He's had this pain in the past, which comes and goes, usually in the chest wall, but at times into the neck, shoulders, up the arms and around the back of his head. He takes medications for anxiety and depression, suffers from diabetes, and has had problems with alcohol in the past. Previous stress tests have not explained his symptoms, and he wonders if a recent increase in work hours is contributing. For Mr. A, the mind and body are not really separate. The feeling of anxiety is chest pain, and his chest pain is often accompanied by anxiety attacks.
Although the medical details are not written in what most physicians would consider the “standard format,” this student captured the patient's perceptions, context, and explanatory model of illness. By the end of the first year, students master the required content of the interview and begin to interview patients explicitly seeking this content, using the linearly structured format of the write-up as a guide—first the chief complaint (CC), then the history of present illness (HPI), past medical history, and so on, regardless of where the patient's narrative is meandering. As they progress through training, learners later begin to apply heuristics that favor symptoms pertinent to hypothesized diagnoses and filter out symptoms that do not. When nonpertinent symptoms are filtered out, unfortunately the patient's explanation of illness and narrative about how it affects his or her life may be filtered out as well. A glistening tear or subtle reference to psychosocial context, inner thoughts, and emotions may now be overlooked or left unattended because of a narrower focus on biomedical tasks or because the observer simply doesn't know how to respond. In this excerpt by the same student seven months later, the medical details are present, but the patient is missing:
CC: Mr. S is a 54-year-old white male with history of myocardial infarction who came to the hospital after experiencing intense dyspnea with racing heart rate.
HPI: Mr. S was in his usual state of health until this evening when he began to experience shortness of breath, wheezing, weakness, fatigue, and inability to lie flat ….
We can see by comparing these two notes from the same student that the structure of the interview and write-up and the force of diagnostic heuristics begin early on to shape students' inquiry and interpretation of the meaning of communication. These qualities then shape the student's sense of his or her own professional role and purpose in relation to patients. These powerful and necessary communicative and cognitive structures become the lenses through which students and clinicians perceive and make sense of the world of medicine. EHRs superimpose an additional layer of complexity onto these lenses.
Acts of dyadic patient–physician communication are complex, requiring building relationships, gathering information, understanding the patient's perspective and context, responding to concerns and emotions, sharing information, making decisions, and enabling self-care.4 Students are introduced to some of these tasks; residents should be competent in them, and practicing clinicians should be expert in all.5 Early evidence indicates that exam room computers and EHRs both help and hinder the communication tasks mentioned above.6
On the bright side, EHRs may facilitate the task of gathering information for minor, acute complaints using point-and-click functions to structure the elicitation and recording of information. Electronic prompts may help students learn what to ask about a presumptive diagnosis and could shape diagnostic thinking. Clinicians can integrate the EHR as a third party, creating triadic interactions by introducing the use of the computer, announcing transitions between conversation and computer-related tasks, maintaining eye contact with the patient more often than with the computer, and sharing data displays, images, and salient information to enable shared decision making.7
On the not-so-bright side, educators and clinicians note that EHR information lacks depth and can be too easily copied and pasted without the reporter necessarily having elicited the history or performed the elements of the physical examination represented. This creates a challenge to professionalism. Technologies that prompt questions pertinent to a particular diagnosis may inadvertently narrow the scope of inquiry prematurely, a common cause of diagnostic error.8 They may also reduce students' motivation and opportunities to develop the skills necessary for diagnostic inquiry. Physicians focused on biomedical information tend to exhibit “screen-driven” information-gathering behaviors, scrolling and asking questions as they appear on the computer rather than following the patient's narrative thread.9
As physicians spend more time interacting with the computer, they have less time available to interact effectively with the patient. In one study, patients seeing residents using exam room computers reported loss of eye contact, reduced time discussing psychosocial factors, and decreased sensitivity to patient responses because of missed nonverbal communication cues.10 Thus, EHRs may magnify an already-prevalent propensity to miss cues about patients' psychosocial and emotional concerns that are essential for contextual understanding, differential diagnosis, management, and, ultimately, for compassionate, patient-centered care.11 Paying attention to the computer and to the patient requires multitasking. Multitasking is the opposite of mindful presence. Moreover, multitasking and task interruption have been implicated as sources of error.12
We have a challenge to meet. Outside the exam room, EHRs, asynchronous communication, and decision support for both patients and clinicians can potentially facilitate informed shared decision making, enable patients' self-management, and improve the health and safety of individual patients and populations. Inside the exam room, for better or worse, these powerful technologies reshape communication, interactions, the patient–physician relationship, and, ultimately, physicians' sense of their professional roles.
EHRs are here to stay. Investigators should study the mechanisms by which EHRs influence reasoning, communication, interactions, and relationships, as well as their impact on patients' trust of physicians, adherence to prevention and treatment recommendations, and health outcomes. Currently, student exposure to EHRs is limited.13 The community of medical educators needs to integrate EHRs into students' learning. Why not create fictionalized comprehensive patient EHRs for problem-based learning that would require students to obtain data through electronic inquiry? It is particularly important to create curricula to teach communication strategies that enable learners to integrate EHRs into patient encounters in ways that foster relationships and communication, particularly while learners' interactional styles are still in evolution. Students' competency in communicating with standardized patients while using EHRs and health information databases could be included in future OSCEs. We teach medical students how to use their stethoscopes early in medical school. If, indeed, as McLuhan3 suggested, media is “the extension of man,” we should teach students how to use these 21st-century extensions appropriately.
Most important, educators must prioritize the teaching and modeling of self-awareness and self-calibration,14 mindful presence, and compassion, lest marginalization of these practices and qualities diminish the purpose and stature of our profession. We can prevent communication and relationships from getting lost in translation by studying the opportunities and challenges created by new technologies. Educators can thoughtfully implement and assess curricula to help learners harness the power of technology rather than being driven by it. Further, the education community must evaluate the impact of EHRs on learners, health care professionals, and the relational experiences and health of patients.
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