Do Computers Really Come Between Doctors and Patients? Is the Future Here?

One of my favorite movies is Back to the Future starring Michael J. Fox.  I must admit after reading this New York Times piece, titled "When Computers Come Between Doctors and Patients" I have to wonder.

Am I fortunate to be coming from the future?  Because I completely disagree with Dr. Danielle Ofri, again.

I've had the privilege and opportunity to work in a medical group which has deployed the world's largest civilian electronic medical record and have been using it since the spring of 2006.  I don't see the issue quite as much as Dr. Ofri did.  It is possible that she examined patients in her office with a desk rather than an examination room.

If placed and mounted correctly in the exam room, the computer actually is an asset and can improve the doctor patient relationship. It is part of the office visit. The flat screen monitor can be rotated to begin a meaningful dialogue between the patient and I. We review the lab work together as well as the trends. Look at xrays. Who needs anatomy flip charts when I can google any image instantly? Patient friendly information to reinforce our discussion is a click away.

The computer can certainly enhance the doctor patient visit. Like any skill, unless we deliberately practice in getting better, we will simply find the new method awkward and unnatural.

And the same goes for emailing patients securely.  An October 2010 article in Pediatrics found that for a 127 families only 5 emails were generated compared to over 2300 phone calls over an 8 month period.  The data doesn't lie.

The conclusion of the article was that -

Although these patients/families expressed strong interest in e-mailing, secure Web messaging was less convenient than using the phone, too technically cumbersome, lacked a personal touch, and was used only by a handful of patients.

So doctors could conclude that patients really don't want to email their doctor.  What a relief because the majority of patients still do not have the option to do so and doctors don't really want to do it.  (Though there could be compelling business reasons not to offer email to patients even if the doctors were technically savvy enough to offer it).

But yet this earlier press release in July 2010 may cause doctors to pause before returning to paper charts, pens, and phones.  This study found that over a two month period, 35,000 patients generated 556,000 email threads.

So what does this all mean?  As doctors we need to change our mindset and look at these changes as opportunities for the medical field to provide care that is increasingly worry-free, hassle-free, and personalized.

The future is here.  That means embracing the computer.

None of my patients would ever go back.

Neither would I.

Speaking of Back to the Future, I understand a limited supply of Marty McFly's shoes are now available for purchase!  Bids are at $4000!

NY Times - Finding a Quality Doctor - Why the Author and Doctors Are Wrong.

The New York Times recently published an article titled, Finding a Quality Doctor, Dr. Danielle Ofri an internist at NYU, laments how she was unable to perform as well as expected in the areas of patient care as it related to diabetes.  From the August 2010 New England Journal of Medicine article, Dr. Ofri notes that her report card showed the following - 33% of patients with diabetes have glycated hemoglobin levels at goal, 44% have cholesterol levels at goal, and a measly 26% have blood pressure at goal.  She correctly notes that these measurements alone aren't what makes a doctor a good quality one, but rather the areas of interpersonal skills, compassion, and empathy, which most of us would agree constitute a doctor's bedside manner, should count as well. 

Her article was simply to illustrate that "most doctors are genuinely doing their best to help their patients and that these report cards might not be accurate reflections of their care" yet when she offered this perspective, a contrary point of view, many viewed it as "evidence of arrogance."

She comforted herself by noting that those who criticized her were "mostly [from] doctors who were not involved in direct patient care (medical administrators, pathologists, radiologists). None were in the trenches of primary care."

From the original NEJM article, Dr. Ofri concluded when it related to the care of patients with diabetes and her report card -

I don't even bother checking the results anymore. I just quietly push the reports under my pile of unread journals, phone messages, insurance forms, and prior authorizations. It's too disheartening, and it chips away at whatever is left of my morale. Besides, there are already five charts in my box — real patients waiting to be seen — and I need my energy for them. 

As a practicing primary care doctor, I'm afraid that Dr. Ofri and many other doctors are making a fundamental attribution error is assuming that somehow doctors can't do both.  She is also wrong in thinking that the real patients waiting to be seen are somehow more important that those whose blood pressure, cholesterol, and blood sugars are poorly controlled and the disease literally eats them up from the inside which could result in end organ damage to the eyes (blindness), kidneys (renal failure resulting in dialysis), extremities (amputation), and heart (coronary artery disease) and possibly premature death.  They aren't in the office and yet are suffering.

Until we as doctors begin to take responsibility for our performance in hard clinical and objective outcomes like glycated hemoglobin levels, cholesterol, and blood pressure, our patients will pay a price.  We should not pretend that bedside manner should trump clinical outcomes nor that clinical outcomes should override the humanistic part of medicine.

It is possible to do both today.  It isn't theoretical.  I only serve as one example.


I'm a front-line primary care doctor who also takes care of patients. I like Dr. Ofri also get a report card on my performance in caring for patients with diabetes.

Based on the medical evidence, my goals are set similarly to hers. For 2010, my performance wasn’t perfect but was 88.6%, 80.8%, and 70% at goal respectively.

I suspect critics will immediately begin to make a lot of assumptions of how these scores were achieved, when Dr. Ofri, another primary care doctor had very different outcomes.  Is it that I am not a quality doctor? Perhaps I’m too driven by data and have no - “soft” attributes like attentiveness, curiosity, compassion, diligence, connection and communication.  Perhaps I "fire" those patients who are not able to achieve good outcomes.

I can tell you many patients wish to join my practice and rarely do people choose to leave it.  The organization I work for also takes the softer side of medicine, a doctor’s bedside manner, seriously.  My employer randomly surveys patients on their experience. Does your doctor listen and explain? Do they know your medical history? Do they partner with you in your health? Do you have confidence in the care they provided you?

For 2010, 92.8 percent rated me very good or excellent on these elements.

So what does this all mean?

We should not automatically assume that doctors with great bedside manner cannot also provide great clinical care.

I can achieve the goals, which patients would want, and still be a doctor with great bedside manner because I work in a functional system like Kaiser Permanente. Primary care doctors are blessed with a comprehensive electronic medical record, are partnered with staff who help patients get the care they need, and are surrounded by specialty colleagues equally as focused to keep patients healthy and well.

So if there is any area of agreement with Dr. Ofri it is that simply giving doctors report cards and telling them to try harder will simply achieve mediocre outcomes.  Until there is a fundamental restructuring on health care is delivered (and simply making appointments longer isn't necessarily going to solve it either), then primary care doctors will continue to leave the specialty in droves.  Doctors need to lead change and use tools and skills honed in other industries, whether the Toyota Production model or lean process, which has been utilized by the Virginia Mason Hospital, or usage of protocols and checklists based on scientific evidence as demonstrated by Intermountain Healthcare and Dr. Brent James.

Until we as doctors lead, we cannot or should not expect improvement in patient outcomes.  We can no longer hide behind the reasons of our Herculean effort or bedside manner as what should really matter and account for something.  Patients expect these attributes intuitively.

With already so many examples of success in the country marrying the art, science, and humanistic part of medicine, the only thing stopping us to re-invent American medicine in the 21st century is simply ourselves.

The Disappearing Family Doctor - Is It a Bad Thing?

The New York Times recently published an article titled the Family Can't Give Away Solo Practice wistfully noting that doctors like Dr. Ronald Sroka and "doctors like him are increasingly being replaced by teams of rotating doctors and nurses who do not know their patients nearly as well. A centuries-old intimacy between doctor and patient is being lost, and patients who visit the doctor are often kept guessing about who will appear in the white coat...larger practices tend to be less intimate"

As a practicing family doctor of Gen X, I applaud Dr. Sroka for his many years of dedication and service.  How he can keep 4000 patients completely clear and straight in a paper-based medical system is frankly amazing.  Of course, there was a price.  His life was focused solely around medicine which was the norm of his generation.  Just because the current cohort of doctors wish to define themselves as more than their medical degree does not mean the care they provide is necessarily less personal or intimate or that the larger practices they join need to be as well.

The New York Times article and many patients typically confuse high quality care with bedside manner.  Not surprising.  In the November 2005 survey by the Employee Benefits Research Institute, 85 percent or more of the public felt that the following characteristics were important in judging the quality of care received:

The skill, experience, and training of your doctors
Your provider’s communication skills and willingness to listen and explain thoroughly
The degree of control you have in decisions made regarding your health care
The timeliness of getting care and treatments
The ease of getting care and treatments

The first three items relate to the ability of a doctor to translate knowledge, training, and expertise into the ability to listen, communicate, and partner with a patient.  This is bedside manner.  The last two items relate to whether a patient can be seen quickly and easily when care is needed.

But beyond bedside manner and ease of getting care, both which are very important, does the public care about getting the right care or just assume that it is a given?  My suspicion is that they assume all medical care provided by doctors is the same, yet research demonstrates the contrary.  One study found that 75 percent of primary care doctors provided the wrong type of colon cancer screening.   Those most likely to do the wrong test after a positive stool screening test?  Those who graduated from medical school before 1978, who were not board-certified, and who were in solo practice. 

Personal relationships between doctors and patients are important, but that should not be the only criteria regarding high quality care.

I love primary care.  I've worked at Kaiser Permanente (KP) in Northern California since 2000, a "larger practice".  The number of patients a full-time doctor cares for is about half of the 4000 patients of Dr. Sroka's.  Doctors have access to a comprehensive electronic medical record that provides real-time information about a patient's lab work, imaging studies, and medications 24/7.  Primary care doctors and specialists can collaborate working off a common database and eliminating the uncertainty that exists in a paper based medical system and when doctors work in isolated solo practices.  Our primary care doctors are supported with a call center which is open all year round day and night to provide patients advice on symptoms and advice on when problems can be safely cared at home, when a doctor's appointment is needed, or when medical care is more emergent.

In other words, doctors can be doctors.

Let's not assume or confuse the rising trend of large group practices or the implementation of more electronic medical records and technology in doctors' offices as automatically dooming doctor-patient relationships to becoming more impersonal.  The rise of social media like Twitter and Facebook have increasingly made society more connected than ever.

If Americans and doctors want solo practices, then they will demand them.  Certainly there are successful solo practice models like the Ideal Medical Practice, which also supported by information technology, that can provide patients with a doctor who is a sole proprietor.  To say all primary care doctors should join large group practices should be absurd because doctors like patients are individuals and one type of practice does not fit all. 

Yet, the fundamental problem with this New York Times piece is the implication that solo practices provide doctor-patient relationships that are more intimate and where patients have a level of trust and confidence in doctors that perhaps exceeds that of thoughtfully designed larger practices.  It offers no evidence if the quality of care delivered is as good.  Let's not use a practice model which was prevalent in the 1960s and assume its passing is a bad thing.  It may not be up to the challenges of the 21st century.

The Rise of Desktop Medicine -- Wrong Terminology, But Right Thing to Do

A recent NY Times article, the Rise of Desktop Medicine, highlighted the use of technology in accessing information (desktop medicine) and how doctors were spending less time with patients (bedside medicine).  Many doctors were concerned about the change and longed for the old days.  Yet, the reality is that with more medical knowledge, doctors must retrieve information from clinical trials, calculate risk of heart attack or osteoporosis, rather than rely on intuition, particularly when data exists.

My biggest problem with this article really was with the term desktop medicine.  I don't like it.  Certainly over the past few decades, our understanding of certain illnesses has become more precise, the interventions and treatments more clear, and therapies more evidence based (precision medicine).  Other illnesses, however, still continue to be more challenging and determining the correct course of action less clear (cognitive or intuitive medicine). 

Precision medicine, a term used by Harvard Business School Professor Clayton Christensen, has simply occurred at the same time computers and the ability to rapidly access information developed.  Imagine if medical science knowledge had evolved but that there was no infrastructure or technology available to retrieve information like clinical trial outcomes quickly.  Doctors would still be treating patients based on intuition rather than science completely oblivious to the latest knowledge.  Research has shown it takes 17 years before outcomes from research studies become commonly practiced in the community.

No desktop medicine isn't the right term to describe the phenomenon in medicine.  It implies doctors are simply indentured servants to computers and technology.  Nothing could be further from the truth.  Generations ago, doctors had few tools and treatments.  When people developed pneumonia, we could do nothing but wait and hope because antibiotics were not discovered yet.  We simply comforted individuals and families.  Many people died.

Today we have more tools, more treatments, and a better understanding of many, but not all illnesses.  To say this additional knowledge and the ability to retrieve this information somehow erodes the doctor patient relationship is incorrect.  We can still be caring and use our technology to access information to make the care of the patient in front of us more precise and personalized than ever before.

No, the terms desktop medicine and bedside medicine are incorrect because they provide the wrong type of connotation.  The former term implies cold and impersonal.  The latter term suggests humanity and comfort.  Better terms with less emotional attachment would be precision medicine and intuitive or cognitive medicine.

I'm a big fan of the art of medicine and bedside manner.   I also love how my computer allows me to make care more convenient and more personal. 

The next generation of doctors must be experts at both bedside manner and using the vast knowledge of medical science to make care precise in areas we have good understanding.  For illnesses where we don't, we still do what we did generations ago, comfort and heal. 

No computer will ever replace that.

Why This Primary Care Doctor Loves his Electronic Health Record

A recent post in the Wall Street Journal Health Blog noted that a study found electronic medical records don't improve outpatient quality.  The authors of the Archives of Internal Medicine article, Electronic Health Records and Clinical Decision Support Systems, correctly points out that we should be skeptical and "doubt [the] argument that the use of EHRs is a "magic bullet" for health care quality improvement, as some advocates imply."

This should surprise no one.  Were we that naive to think that simply installing health information technology (HIT) in the medical field would generate significant improvement in outcomes?  Does simply installing computers in our classrooms improve educational test scores?

Of course not.

The excellent commentary after the article makes some plausible reasons why the clinical decision support (CDS) didn't seem to improve outcomes on 20 quality indicators.  First, it isn't clear that the CDS implemented across the various doctors' offices and emergency rooms actually addressed the indicators studied.  Second, the data studied is already dated (from the 2005 to 2007 National Ambulatory Medical Care Survey), a long time in technology terms (iPhone first debuted in 2007).  The authors of the original article also point out that there is some evidence that institution specific use of CDS actually improves quality.  Whether this can be scaled to the national level is the question.

In other words, it isn't just that perhaps CDS failed, but rather the robustness of the system was inadequate, that doctors failed to use them, or just as importantly patients were unswayed by the doctors reminded by the CDS to do the right thing. One of the 20 quality indicators studied was in fact the appropriate antibiotic use in viral upper respiratory infections.  As most people know already, there is not typically an appropriate antibiotic to use for a virus.  It's a virus.  It does, however, take good bedside manner to inform and educate an ill patient!

As someone who has had the benefit of a robust electronic health record since the spring of 2006, I know I'm incredibly lucky.  In an April 2009 New England Journal of Medicine article, only 4 percent of doctors nationally have a fully comprehensive EHR that I take for granted daily. Only 1.5 percent of hospitals have a comprehensive EHR, which I also have access to.  CDS is also an incredibly helpful tool and an excellent reminder to provide the right care every time.  It is a safety net.  Understandably some EHRs aren't that good, the CDS is clunky, and certainly the one I use is good, but not perfect.

The real issue isn't finding a perfect EHR, but rather how do we address the culture of the medical profession. There is something still heroic and mystical about a lone doctor, independent, smart, and getting the job done.  Indeed, to get into medical school, one has to be self-motivated, persistent, and determined.  Why on earth would we need a computer to help us?

Frankly, because it makes us better doctors.  CDS frees up time and mental energy.  I don't have to remember the latest guidelines on immunizations, repeating blood work, or treatment of illness like coronary artery disease, congestive heart failure, and hyperlipidemia.  Most of these diseases are well understood and often under a protocol, something known as precision medicine, a term used by Harvard Business School professor Clayton Christensen. 

Now I can focus on if the patient in front of me is an exception to the protocol as well as thoughtfully diagnose and treat their ailments which don't fit any protocol (cognitive medicine) because science hasn't evolved to that level of understanding.  I'm a big believer in the history and physical exam and how the use of HIT can make care more personal.  Having real-time access quickly and reliably to medical information and data 24/7 is important to make this happen.  Instead of hunting for lab work in a paper chart or trying to find a specialist's consultation, I can access the information I need rapidly and focus on the patient in front of me.


Sadly, however, many doctors don't feel the same way. Perhaps it is a generational thing. Perhaps it is because their EHR is inadequate.  It might also be, however, our training and tradition which limits us from improving.  If anything, the medical profession needs to emulate ourselves after the aviation industry where technology is used to support decision making and make pilots and flying even safer and better.  We are where our aviation colleagues were in 1935 as noted in Dr. Atul Gawande's New Yorker piece, the Checklist.  Because, really, CDS is essentially a checklist.

In the situation where a patient doesn't fit CDS, then we get to do what we do best and that is use all of our training to get a patient better.   HIT, EHR, and CDS are things the next generation of doctors must accept that will make the care we provide more personal than ever before.  In the end, that is what patients really want.

This is why I love my EHR so much.

Improving Healthcare System Won't Save Money

While healthcare reform is gaining momentum (and rightly so), plenty of experts believe that improving the healthcare system will save money.

Don't believe it.

A recent USA Today piece titled, "Do smokers cost society money" suggests that smoking and dying earlier saves the healthcare system and other benefit programs. It may be that healthier individuals living longer, and consequently having the opportunity to have more chronic illnesses like diabetes and cancer, cost more.

From the article -

• Smoking takes years off your life and adds dollars to the cost of health care. Yet nonsmokers cost society money, too — by living longer.
• smokers die some 10 years earlier than nonsmokers, according to the CDC, and those premature deaths provide a savings to Medicare, Social Security, private pensions and other programs.
• A Dutch study published last year in the Public Library of Science Medicine journal said that health care costs for smokers were about $326,000 from age 20 on, compared to about $417,000 for thin and healthy people. The reason: The thin, healthy people lived much longer.

This is something I've always thought was a possibility. It makes some intuitive sense. Back in the 1950s, if a man died of a heart attack that would be the only cost to the healthcare system. Now as people live longer as we know better on what we must do to stay healthy and well, then they have more opportunities to not only become ill, but also injured, as well as need surgery for joint replacements, etc.

The additional wrinkle is that even the smoker now is likely to survive what was a fatal heart attack a generation ago, presumably quit smoking and also develop illnesses that can't be current, but controlled with a dizzying array of medications.

Why is this important? Healthcare reformers keep talking about cost savings to the system which isn't likely. Instead of claiming huge savings, we should be talking on how better to shift costs from expensive medical expenses like emergency room care and hospitalization for an uninsured patient with a heart attack to providing affordable health insurnace to the person to completely avoid the heart attack.

The healthcare system will still cost employers and the government a lot of money. We as a nation shouldn't expect savings from requiring doctors and hospitals to have electronic medical records (which is the right thing to do) or other touted improvements despite what the experts tell us. The irony and curse of our healthcare system is if we are as good at preventing premature death, by definition we are extending life and the likelihood of more healthcare costs for individuals saved. Can't argue with more time with family and friends.

So be cynical about stories that fixing the healthcare system will save money. It won't. What is far more important is given the amount of money we spend can we ensure it is wisely spent so all of us have the potential to live productive healthy lives?