"We cannot get to where we need to go by remaining where we are."
–Adopted from Max de Pree
Leadership Is an Art
In our last column, we discussed an article published in JAMA that showed a crayon drawing that was given a doctor by the 7-year-old girl who had drawn the picture (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 of the drawing was clear, that the way we are viewed by our patients is changing. What is equally remarkable though, when you view the picture from the girl’s perspective, is that there was nothing sad about the drawing. The colors where vivid and all the figures in the room were smiling. Why would there be anything sad about this encounter? This is the world that the 7-year-old knows, it’s her reality, a world in which attention is regularly divided, and electronic devices are how information is stored and through which communication occurs. This fact is difficult to integrate and understand for those of us who are a bit older but is simply an ordinary part of life, like milk in a jar or plastic lids for those young enough to know no other world. Nonetheless, the concern remains that we need to be careful that the patient’s needs do not become buried underneath the clicks and hums of the machine.
There are many physicians who are sad about the demise of the paper chart. We hear from those people daily. If we acknowledge the complexity of our needs, then we see that the old paper-based chart system, while easier to use than an electronic chart, simply does not allow us to record information in a form that is retrievable for the evolved purposes for which we are now keeping records. Population management in not just a buzz word, it is the area toward which our care of patients is evolving if we are to truly make an impact on improving their health. So EHRs are a necessary component of this evolution. Our challenge, as physicians who are now beginning to care for populations as well as individual patients, is how to balance and integrate the immediate needs that occur in the exam room – the need to provide the proper diagnosis and treatment, to record data, and to truly listen to the patient. To make sure that the patient feels heard. A colleague of ours who has thought a lot about electronic records, Dr. Keith Sweigard, feels that the EHR will eventually be a tool that will facilitate medical humanism. To use his words:
"Technology will paradoxically foster humanism in medicine. As we implement [EHRs] with standardized templates, care pathways, and order sets, patients will more likely receive the same work-up and evidence based interventions from any care provider. In that scenario, what will become the distinguishing factor that a patient selects one physician over another? Access will certainly be a factor, but ongoing relationships will depend on connecting with the patient on a humanistic level – warmth, sensitivity, compassion, and empathy. In other words, the dictum of patients choosing their physician based on access, affability and then ability – in that order – will be more important than ever!"
The literature supports that how well a doctor communicates influences patients’ satisfaction, sense of well-being, overall health, malpractice suits, and may even influence health care costs. When we are ill, we yearn for two things – to be well, and for someone to understand our suffering. Science and technology improves our chances of being well, but it does not address our need to be understood. The doctor is in a unique position to provide for both aspects of what the ill person needs: to help alleviate their suffering and to understand their unique human position in the world, as all suffering is unique. In order to fulfill this role, there has to be ongoing reinforcement of the “centrality of relationships” in medical care (Ann. Intern. Med. 2008;149:720-4).
We agree with Dr. Sweigard’s assessment that, as the protocols and decision support become easier to use and as the quality tools that EHRs will provide become more sophisticated, what will distinguish us from one another and what payers will increasingly support, is our attention to the patient and his or her needs as a person. That attention to the person will be measured through patient satisfaction, and that quality measure will be reimbursed. It will not be difficult to figure out what medication to use next for this person’s hypertension or elevated glucose. The decision support will be there, integrated and easy to use, and our smile and perhaps our attentiveness to the small tear welling in the corner of a patient’s eye, will again distinguish us and allow us to connect as human beings. In a future column on electronic health records and humanism, we will discuss strategies to help us to use the electronic record to accomplish these goals.