Listen, Observe, Think, Speak and Act (Not Keyboarding)
I walked into the residents’ work room for my afternoon of being the attending physician. Four residents were busily working away on computers. They were all in their cubicles catching up on patient data, reviewing lab work, adding notes, checking orders, seeing what might have happened recently with their patients. While their diligence and hard work impressed me, there seemed to be something wrong with this picture. Is this the way the modern physician works?
Computers are a great advance for medical practice. Now, for the first time, all of the patient’s information is in one place and readily available. Critical functions like checking lab work, writing new orders, requesting consultations, comparing the past with the present, are all done rapidly with points and clicks. At UCSD, we use the new Epic record system and no one would go back to paper. We all have a sense that we are now in modern 21st century medical practice, and that the paper ways were indeed primitive. Having access to the entire patient’s data throughout the system makes clinical decision making much more informed.
When the patients are brought into the visibility of their consultation reports, lab results, x-ray reports, flow sheets of their vital signs, they are duly impressed. As we prescribe medications accurately, with automatic checking for spelling, dosing and drug interactions, then have the prescription autofaxed to their preferred pharmacy, it seems magical. All patients leave with a printed summary of their visit, with confirmation of their diagnoses, orders and all their instructions.
After the patient leaves, the real keyboarding begins. Where do we find time to accurately document the visit in the “progress note”? With other patients waiting, we put off this “charting” to a later time. With access to the patients’ records from any computer, including at home, we defer completing the charts to the evening, or the next day, or whenever. Every clinic session comes with its burden of documentation which must get done while we remember it. The In Box of patient messages and reports grows just like our e-mail, and keeping up requires “keyboarding time” filling up much of our waking hours. Did we go to medical school and residency to spend our life pounding away on computers?
When I looked at the four residents keyboarding away silently and with their backs to me and each other, I had an epiphany. This will go away! This is the primitive early computer era. Working with computers should not require keyboarding. We are not at our best as physicians typing into machines. We are at our best when listening, observing, thinking, speaking and acting.
The art and science of medicine are using the best medical knowledge gained from many sources over time to render excellent clinical judgments for patients using well developed communication and relationship skills. The time honored methods of clinical excellence are careful listening and observation, thinking assisted by knowledge of both the diseases at hand and the patient, and acting on this as a healer. We physicians are at our best standing up or sitting with patients and using these clinical skills. We must be fully present with our patients to do this well.
The complexity of modern medicine exceeds the inherent limitations of our human minds. We simply cannot store all necessary medical knowledge and retrieve it for patient care accurately at all times. We may have vast knowledge about our established patients, but we cannot remember accurately all their important clinical information. Paper records are woefully inadequate for information retrieval. This is where computers come in. Computers are essential for modern medicine. Not only do they make the patient’s clinical information readily accessible, but they may combine this with the best of medical knowledge to guide clinical decision making. Computers are the new “third element” in the exam room and at the bedside.
But will we always have to keyboard our way into the computer’s vast resources? Certainly not! I can keyboard as well as most in my generation (which isn’t saying much). I often reflect that my most important class in high school was typing. Forty words a minute has been a useful skill throughout my professional life. Of course the younger generations put me to shame. Keyboarding is now taught in the third grade and the residents move much faster than I can. They even answer questions and talk about other things without stopping their hands on the keys! To them, keyboarding is second nature. However, when keyboarding, they are really not listening, observing, thinking much or acting except through the machine. There is a better way and I hope it comes soon.
There will be a future when we will be able to talk with our machines. Like Hal in 2001 A Space Odyssey, our computers will seem alive to us. We will talk to them, ask them questions, and have them look things up instantly. They will assist us greatly, almost completely, in the medical knowledge part and with patient information. We will be uninterrupted in our listening, observing, thinking, speaking and actions with patients. Like Dr. Bones in Star Trek, we will have the power to heal aided by superhuman tools while we stay completely human with our patients.
Voice recognition technology is now about 98% accurate. It learns with the voice of its user. I can’t wait until it becomes standard in clinical medicine with our machines. The use of the internet and clinical uses of computers took off just a decade ago. We are still very early in this revolution. I hope to be alive and still working we our use of computers is beyond the keyboarding era. They will be great companions but I want to use my hands for healing.