EHRs, Medicine, and Humanism, Part 1


"I won’t insist that the patient is a soul,

But he’s a something, possibly laughable,

Or possibly sublime, but not quite graphable.

Not quite containable on a bed chart.

Where science touches man it turns to art."

–John Ciardi

The Saturday Review, Nov. 18, 1967

"Not quite graphable" is how John Ciardi described patients in a wonderful poem titled "Lines From the Beating End of the Stethoscope." In that poem, which he read at the inaugural for the new president of New York Medical College, he describes medicine, as the title suggests, from the patient’s point of view.

Dr. Neil Skolnik and Dr. Chris Notte

The poem was meant to be a reminder of the subtle needs that patients have during their encounters with doctors around some of the most important decisions and events in their life, their health, and their physical and mental well-being. It was a reminder to doctors that patients’ needs are varied, complex, difficult to discern, and not able to be fully explained or understood through math and science.

How Mr. Ciardi had such insight 45 years ago into the issues that we are all facing today is remarkable. It is a rare day in which I do not hear from one of my colleagues about how the computer screen is getting between them and their patient.

We talk in conferences about how we have become so focused on the needs of the computer that the needs of the patient get left behind. How we are so busy making sure that the "checklist" of tasks for meaningful use have been completed, that the meaningful encounter – that feeling that the patient keeps with them after they leave the doctor’s office that they have encountered someone who cares about them – recedes into the background, while the foreground is filled with clicks and navigated pages.

A recent commentary in JAMA displayed a crayon drawing by a 7-year-old girl, which was given to her doctor (JAMA 2012;307:2497-8). The drawing showed the girl sitting on the exam table, with her sister and mother in nearby chairs, while the doctor was sitting hunched over a computer with his back to the patient and her family.

The message implicit in the publication of this drawing is clear – that patients are now beginning to see us in ways that are different than how we have traditionally seen ourselves. Ways that are frankly embarrassing. I don’t think that any of us go to the office desiring to be the kind of doctor that a child or an aging adult perceives as hunched over a computer screen distractedly listening to their concerns while typing away with our back toward them.

Integrating the electronic record into the exam room brings with it certain inherent tensions that potentially interfere with the interaction of patients and their physicians. These tensions are consistent with the tensions imposed by the necessity of documenting the patient encounter, and this tension exists whether the physician is using paper or electronic media.

Once this fact is understood, and the importance of maintaining an empathic interpersonal encounter with the patient is accepted as something that cannot be compromised, we can begin to thoughtfully and honestly develop methods that allow us to keep the encounter personal while integrating the electronic medical record into our office.

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