Alice rubbing her pregnant belly was the first thing I saw when I opened the door to the exam room. She was angry at having been told she had HIV by a doctor who had then dismissed her and she was angry at me, her new doctor. It took many intimate conversations for us to get to know one another. Eventually, she learned to trust me, and she became one of my most beloved patients.
Now when I meet a patient for the first time, our conversation is interrupted because I need to share the information the patient imparts with the computer, the stranger in the room that sits conspicuously between us.
In 1993, after finishing my residency in internal medicine, I started working in a clinic for patients with HIV. Friends wondered about the toll that caring for patients who were all going to die would take. Paradoxically, I found it inspiring. I measured myself against my patients. Could I be as noble as many of them were? They fought hard, rallied against pain, and battled stigma. I discovered myself as a physician through my relationships with them. Those years held for me the opposite of burnout. I was not saving lives, but I was accompanying my patients in their lives.
Fast forward 20+ years. Miraculously some of my patients from all those years ago are alive and I still care for them. Alice sadly is not, but her son Eric, born with HIV, is now one of my patients. But our relationship is different. Ours is a ménage a trois. The third party in our relationship is the computer in the room that holds the electronic health record that has become the focus of the encounter.
My gaze rests briefly on my patient but lands more purposefully on the computer screen that garners my attention for most of the visit. I listen to my patient’s concerns but then discuss them with the computer. I talk with the computer. Sometimes I yell at the computer when it does not converse easily with me, not finding the required information, shutting off when it feels like it. Once, one of my patients admonished me, “You need to talk nicer to it.”
Perhaps the younger generation will be more facile with electronics in a way that will enable them to engage easily with the electronic health record and the patient simultaneously. But will they ever experience the privacy of two people engaged in a personal conversation in which the focus is the story that the patient is telling the physician? Will they ever experience trust that is developed through a special, unique, and therapeutic intimacy? Now, my attention to snatches of the story competes with my absorption in a screen to ensure that the required boxes have been clicked. This loss of intimacy is not unique to the stories of patients with HIV; it is found in the stories of patients with other complex illnesses that may involve stigma, loss, risk, and worry.
We hear a lot about burnout. I cannot help but wonder if an antidote is relationship. Those early days of caring for one patient at a time, like Alice, were enriching and powerful and did not leave me feeling distracted in the way that today’s ménage a trois does.
With Alice’s son, the conversation is different. He checks his cell phone during our visit. Every so often there is a bing, and he answers the text with nimble fingers. It gives me time to address my computer. His eyes gaze down and mine forward as we examine our screens.
Nancy R. Angoff, MD, MPH, MEd
N.R. Angoff is associate dean for student affairs and associate professor of internal medicine, Yale School of Medicine, New Haven, Connecticut; e-mail: firstname.lastname@example.org.