Dr. Bynum is attending faculty, National Capital Consortium Family Medicine Residency, Fort Belvoir Community Hospital, Fort Belvoir, Virginia. At the time this commentary was written, he was a third-year resident.
Funding/Support: None reported.
Other disclosures: None reported.
Ethical approval: Reported as not applicable. The patient in the opening vignette is not identifiable based on the information presented.
Disclaimers: The opinions and statements in this commentary are the responsibility of the author, and such opinions and statements do not necessarily represent the policies of the U.S. Air Force, U.S. Army, U.S. Navy, Department of Defense, Department of Health and Human Services, or the United States and its agencies.
Previous presentations: This commentary is a written adaptation of a short speech given by the author at the 2012 Association of American Medical Colleges’ Annual Meeting as part of the Organization of Resident Representatives/Organization of Student Representatives/Group on Regional Medical Campuses plenary session “The Sky’s the Limit for the Future of Medical Education: Mentoring, Leadership, and Innovation,” on November 2, 2012, in San Francisco, California.
Correspondence should be addressed to Dr. Bynum, 9300 DeWitt Loop, Fort Belvoir, VA 22060; telephone: (571) 231-1803; e-mail: firstname.lastname@example.org.
A full 14 minutes into the 20-minute appointment, I realized that the patient sitting in front of me in the exam room was softly crying, her hands cradling the box of tissues that she had searched out herself. I had spent the majority of the appointment engaged in a frantic search through her extensive electronic medical record, and I cursed myself for being so buried in the computer screen that I had hardly glanced in her direction. Mrs. S had end-stage cancer, and my misguided chart review had revealed countless studies, medical therapies, and procedures that had done little to change her very poor prognosis. I turned the computer monitor off, wheeled my chair over, and gently took her hand. With five minutes left in the appointment, I discovered the real reason she had come to see me. Having accepted the fact that technology and medicine no longer offered her the hope of a cure, she was interested in learning more about comfort care, a decision that left her feeling sad and anxious. In this fragile and vulnerable state, she sought warmth, compassion, and reassurance, none of which could be found anywhere near the ever-present computer that noisily hummed as the encounter continued.
I consider myself an emotionally intact person who is sensitive to the needs of others, a characteristic that serves me well as a family medicine physician. I am also intrigued by the limitless promise of technology, both in medicine and in our everyday lives. Like most of my generation, I grew up in the era of the development of the personal computer and have witnessed an unprecedented technological revolution over the past 20 years. I fondly remember the days when computers ran on MS-DOS, cell phones came in bags, and 20-pound video cameras turned 10-year-olds into amateur movie producers who would excitedly watch themselves on their analog televisions the next day. Those were the days when human beings scanned your groceries, kids played outside while their parents shared beers on the porch, and your circle of friends was defined by who you could fit around your dinner table. Those were also the days when everyday tasks took time to complete, purchasing anything required getting in your car and going to the store, and communicating with others required a visit, phone call, or handwritten letter rather than “I’ll text you when I’m on the way.”
Now, a mere 20 years later, we live in a digital world with technologies that have made the human race more interconnected, efficient, and informed than ever before. We have developed effective ways of communicating with each other and of accomplishing the tasks of everyday life that used to take a significant amount of time to complete. Technology has allowed us to integrate freely and widely with the people in our lives and has given us the ability to develop and foster relationships with less effort. As a result, we are able to stay connected with an impressively large number of people in a way that completely bypasses geographical and logistical barriers.
However, for all of its merits, this technological renaissance comes with one major and unintended consequence: we are losing sight of the value of direct human contact. In this case, I am not referring to human contact as the ability to know about another’s life or to communicate with her frequently, but rather, as the emotional bond and personal connection that we share as human beings, the generation and maintenance of which requires time, energy, effort, and direct interaction, each of which the technological renaissance tends to minimize. The conversations, both menial and important, that we once had in person now occur through hastily written text messages and e-mails, and the videos and pictures we used to create and laugh about together now stream out of our iPhones and onto a Web site that we later look at while we sit alone at our desks. The friendly grocery bagger, the overworked airline agent, and the eccentric bank teller with whom we used to frequently interact have all been replaced by automated kiosks that are neither friendly, overworked, nor eccentric and that refuse to smile back at you no matter how hard you try. In short, the great social progress that we are making through our technological innovation comes at the cost of the human connections and emotional bonding that help define the human experience.
This paradox of social progress and individual isolation is not unique to the activities of everyday life; it is equally prevalent in the world of medicine. As a medical community, we are among the most innovative and technologically advanced professions, and our creations and capabilities have extraordinary benefits, both to us and the public. We can operate on live human beings with a robot and transplant a heart, a liver, and even a face from one person to another. We can save the life of a quadruple amputee and offer him the ability to walk and write again. We have generated electronic systems that will one day allow a patient’s records to follow her wherever she may go. We have eradicated some of history’s most devastating infections, and we have developed highly effective medicines to prevent common and deadly diseases before they ever develop. Mrs. S was herself a modern-day medical miracle whose seemingly truncated life had been prolonged for years by advanced surgeries, high-fidelity radiation, and experimental chemotherapy. Our medical innovations allow people like Mrs. S to achieve longer, healthier, and more prosperous lives, helping to propel our society forward at a rate that mirrors that of our technological accomplishments.
However, in medicine, as in our daily lives, innovation and technological advancement come at the cost of the emotional, human connection we have with our patients. We are becoming increasingly reliant on technology to diagnose conditions that we once discovered by simply talking to our patients and laying our hands on them, and we are constantly inundated with so much information that we hardly have time to sit and listen to our patients much less to examine them in a way that inspires confidence or to break difficult news in a way that shows them we care. Thus, while technology allows us to make better decisions on behalf of our patients, it also hampers our efforts to effectively communicate and nurture the bond that must exist for them to accept and act on these decisions.
In my experiences as a family medicine physician, most of my patients care as much about the way in which I deliver the results and interpretation of their tests as what those tests actually reveal, and there is a direct correlation between their perception of how much I care and their willingness to follow my guidance. Multiple studies have demonstrated this link between physicians’ interpersonal skills and patients’ overall satisfaction1,2 and adherence to prescribed therapies in chronic conditions, such as diabetes,3 hypertension,4 and glaucoma.5 A 2009 meta-analysis of 106 studies showed a powerful link between the quality of a physician’s communication skills and his or her patient’s adherence to prescribed therapies.6 In the realm of end-of-life care, high-quality, patient-centered communication has also been shown to improve patients’ satisfaction and to facilitate advanced care planning,7 while poor communication about terminal illness may lead to patients’ increased distress, poor decision making, and worsened clinical outcomes.8 In the case of Mrs. S, what she sought from me was warmth, compassion, and an honest discussion about these difficult end-of-life issues, and, in my frantic efforts to leverage technology, I nearly missed the opportunity to emotionally connect with her and provide her with the type of care she needed most.
We, the current and future leaders in academic medicine, need to acknowledge both the awesome power and the unintended consequences of technological advancement, and we have an obligation to ensure that innovation only enhances rather than detracts from the care we offer our patients. To accomplish this goal, we should not only continue to innovate in all aspects of medical practice but should also make a more concerted effort to leverage technology in a way that improves our ability to effectively communicate and connect with our patients. Specific areas for improvement include creating more user-friendly electronic medical records that speed us up rather than slow us down9; using non-physician-mediated resources, such as the Internet and smartphone apps, to enhance our in-person counseling and patient interactions; and further refining our use of asynchronous communication (i.e., e-mail, mailers, and text messaging) to facilitate our intervisit information sharing and support of patients.10 All of these tools already exist, but their use is often cumbersome and inefficient. Improved integration of these tools into our daily practice will allow us to be more available to our patients and more engaged in their care rather than distracted from it.
While enhanced integration of technology into our practice will be beneficial, we also need to make a more concerted effort to simply set aside these tools at times so that we can better connect with our patients. We cannot allow ourselves to become automated medical kiosks that offer sound, innovative medical advice but that lack personality, compassion, and emotion and that fail to inspire our patients to make the difficult but beneficial changes that will lead to better health. As educators responsible for training the next generation of physicians, we must first ensure that we are modeling these humanistic aspects of medicine, then we must place a greater emphasis on teaching our learners how to apply these values in an increasingly innovative medical landscape.
To achieve this goal, we must (1) leverage master clinicians to teach our students and residents nontechnological, core clinical skills, such as how to conduct the physical exam, break bad news, and communicate with dying patients, while looking to the existing literature for practical ways to better incorporate these skills into the curricula11,12; (2) use the principles of narrative medicine to develop greater self-awareness of our own feelings about disease and greater empathy for our patients through the telling of their stories13,14; (3) strengthen existing competencies, such as physician–patient communication, relationship building, and cultural sensitivity, and incorporate new competencies or milestones, such as responsible and thoughtful use of technology and narrative competence, into evolving efforts such as the Accreditation Council for Graduate Medical Education’s Next Accreditation System Milestone Project and the Association of American Medical College’s Competency-Based Admissions projects13,15,16; and (4) continue to investigate the barriers, perceptions, and desires that influence connectedness between patients and physicians and the role that technology plays in this relationship.
In all of these efforts, which emphasize the how of communication and human connection, we need to remain equally focused on the why: that health, disease, and dying are emotionally complex forces in our patients’ lives and have real effects on their behaviors, perceptions, and health outcomes. Understanding and responding to these human complexities requires a set of skills that largely exist outside the realm of technology but that must be taught alongside an explosion of complex and exciting medical innovation. Helping our learners to master these new technologies without sacrificing their ability to connect with their patients will undoubtedly be one of the great challenges of educating the next generation of physicians.
Finally, all of us, educators, learners, and practicing physicians alike, need to slow down and take the time to nurture the connections we have with the people in our lives, reminding ourselves just how lucky we are to have the capacity for human connection and the opportunity those connections give us to make life better for those around us. We need to take the time to visit and write to our friends, pick up the phone and call our loved ones, explore the neighborhood with our children, peruse old photo albums with our parents, and share a beer on the porch with our neighbors. Likewise, we need to take the time to listen to our patients, give them our full and undivided attention, examine them well, hold their hands when they need it, and connect with and attempt to relate to the circumstances surrounding their lives. When we do all of these things, the human connection and individual growth we experience will make our innovations that much more meaningful.
Mrs. S died a few short weeks after transitioning to comfort care, and, in her final days, compassion, empathy, and human connection brought her peace and filled the gaps created by the limitations of technology. Rather than continuing to serve as an automated medical kiosk fresh out of solutions, I reengaged her on a human level and became a part of her graceful and peaceful journey to death, a process that changed my life as well. Mrs. S’s experience reminds us that, as we continue to innovate at a remarkable rate, we must remember that human connection, not technology, is the greatest gift we have to offer to our patients and one another.
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. Accessed October 23, 2013