Conference Coverage

Patients need physicians who see – and feel – beyond the EMR


 

EXPERT ANALYSIS FROM RSNA 2019

– Speaking to a rapt audience of radiologists, an infectious disease physician who writes and teaches about the importance of human touch in medicine held sway at the opening session of the annual meeting of the Radiological Society of North America.

Dr. Abraham Verghese, of Stanford (Calif.) University Courtesy RSNA

Dr. Abraham Verghese

It wasn’t hard for Abraham Verghese, MD, to find points of commonality between those who sit in dark reading rooms and those who roam the wards.

The EMR, Dr. Verghese said, is a “system of epic disaster. It was not designed for ease of use; it was designed for billing. ... Frankly, we are the highest-paid clerical workers in the hospital, and that has to change. The Stone Age didn’t end because we ran out of stone; it ended because we had better ideas.”

The daily EMR click count for physicians has been estimated at 4,000, and it’s but part of the problem, said Dr. Verghese, professor of medicine at Stanford (Calif.) University. “For every hour of cumulative patient care, physicians spend 1½ hours on the computer, and another hour of our personal time at home dealing with our inbox,” he said. EMR systems may dominate clinical life for physicians, “but they were not built for our ease.”

Dr. Verghese is a practicing physician and medical educator, and is also the author of a body of fiction and nonfiction literature that delineates the physician-patient relationship. His TED-style talk followed opening remarks from Valerie Jackson, MD, the president of the Radiological Society of North America, who encouraged radiologists to reach out for a more direct connection with patients and with nonradiologist colleagues.

The patient connection – the human factor that leads many into the practice of medicine – can be eroded for myriad reasons, but health care systems that don’t elevate the physician-patient relationship do so at the peril of serious physician burnout, said Dr. Verghese. By some measures, and in some specialties, half of physicians score high on validated burnout indices – and a burned-out physician is at high risk for leaving the profession.

Dr. Verghese quoted the poet Anatole Broyard, who was treated for prostate cancer and wrote extensively about his experiences.

Wishing for a more personal connection with his physician, Mr. Broyard wrote: “I just wish he would brood on my situation for perhaps 5 minutes, that he would give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh, to get at my illness, for each man is ill in his own way.”

It’s this opportunity for connection and contemplation that is sacrificed when, as Dr. Verghese said, “the patient in the bed has become a mere icon for the ‘real’ patient in the computer.”

Dr. Jackson, executive director of the American Board of Radiology, and Dr. Verghese both acknowledged that authentic patient connections can make practice more rewarding and reduce the risk of burnout.

Dr. Verghese also discussed other areas of risk when patients and their physicians are separated by an electronic divide.

“We are all getting distracted by our peripheral brains,” and patients may suffer when medical errors result from inattention and a reluctance to “trust what our eyes are showing us,” he said. He and his colleagues solicited and reported 208 vignettes of medical error. In 63% of the cases, the root cause of the error was failure to perform a physical examination (Am J Med. 2015 Dec;128[12]:1322-4.e3). “Patients have a front side – and a back side!” he said, to appreciative laughter. A careful physical exam, he said, involves inspecting – and palpating – both sides.

The act of putting hands on an unclothed patient for a physical exam would violate many societal norms, said Dr. Verghese, were it not for the special rules conferred on the physician-patient relationship.

“One individual in this dyad disrobes and allows touch. In any other context in this society, this is assault,” he said. “The very great privilege of our profession ... is that we are privileged to examine [patients’] bodies, and to touch.”

The gift of this ritual is not to be squandered, he said, adding that patients understand the special rhythm of the physical examination. “If you come in and do a half-assed probe of their belly and stick your stethoscope on top of their paper gown, they are on to you.”

Describing his own method for the physical exam, Dr. Verghese said that there’s something that feels commandeering and intrusive about beginning directly at the head, as one is taught. Instead, he offers an outstretched hand and begins with a handshake, noting grip strength, any tremor, hydration, and condition of skin and nails. Then, he caps the handshake with his other hand and slides two fingers over to the radial pulse, where he gathers more information, all the while strengthening his bond with his patient. His exam, he said, is his own, with its own rhythms and order which have not varied in decades.

Whatever the method, “this skill has to be passed on, and there is no easy way to do it. ... But when you examine well, you are preserving the ‘person-ality,’ the embodied identity of the patient.”

From the time of William Osler – and perhaps before – the physical examination has been a “symbolic centering on the body as a locus of personhood and disease,” said Dr. Verghese.

Dr. Jackson encouraged her radiologist peers to come out from the reading room to greet and connect with patients in the imaging suite. Similarly, Dr. Verghese said, technology can be used to “connect the image, or the biopsy report, or the lab test, to the personhood” of the patient. Bringing a tablet with imaging results or a laboratory readout to the bedside or the exam table and helping the patient place the findings on or within her own body marries the best of old and new.

He shared with the audience his practice for examining patients presenting with chronic fatigue – a condition that can be challenging to diagnose and manage.

These patients “come to you ready for you to join the long line of physicians who have disappointed them,” said Dr. Verghese, who at one time saw many such patients. He said that he developed a strategy of first listening, and then examining. “A very interesting thing happened – the voluble patient began to quiet down” under his examiner’s hands. If patients could, through his approach, relinquish their ceaseless quest for a definitive diagnosis “and instead begin a partnership toward wellness,” he felt he’d reached success. “It was because something magical had transpired in that encounter.”

Neither Dr. Verghese nor Dr. Jackson reported any conflicts of interest relevant to their presentations.

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