By Matt Wood
Maybe you’ve had this experience at the doctor’s office: Your physician enters the exam room, and instead of asking “What brings you here?” and speaking face to face, he sits down at the computer and starts peppering you with questions, typing away furiously.
With the introduction of electronic medical records into clinics, physicians can pull up your entire medical history with a few clicks and take detailed notes about your exam. This is an invaluable tool, but the presence of a computer in the exam room can create awkward situations with patients, who may resent the intrusion of this unacknowledged third party in the room. To fix this modern-day breakdown of communication, two fellows from the University of Chicago Medicine are developing a curriculum to teach medical students how to use electronic medical records effectively while keeping their focus on the patient.
Maria Alcocer Alkureishi, MD, assistant professor of pediatrics, and Wei Wei Lee, MD, assistant professor of medicine, are currently in the Medical Education Research Innovation Teaching Scholarship (MERITS) fellowship program, a one-to-two year opportunity for fellows and faculty at the University of Chicago for training and mentorship in medical education. They first noticed how the presence of computers in the exam room complicated the dynamic between doctors and patients during their clinical rotations. Some physicians adapted to the new tools and were able to fit them into exams naturally, while others struggled.
“We’ve seen it go well and not go well with colleagues,” said Alkureishi. “The people who already had good communication skills actually did well. The computer amplified their skills. For the people who did poorly without the computer, introducing it to the exam room just made things worse.”
Those successes and struggles inspired the pair to address the challenges of incorporating what should be an essential tool into clinical practice. “It’s technology that you can use to really benefit people. I think it was those experiences of both seeing it done poorly and seeing it done well that made me interested in integrating that into the medical student curriculum,” said Alkureishi.
They decided to pursue this idea as a group project for their fellowship. The curriculum they proposed would incorporate a variety of teaching tools to show students how to engage a patient with their electronic medical records on a computer screen, and provide opportunities to observe and critique each other as they practice their interactions. This could include video analysis, role-playing and interactive lectures.
Their tips center on keeping attention directed toward the patient and not the screen. Engage with the patient directly to begin the exam and don’t sit down immediately to type. Take a few notes that can be filled in later instead of trying to record every last detail during the visit. Position the lower body toward the patient while using the computer, and turn the screen to share visual information like charts and graphs. The trick is to turn these behaviors into habits that help physicians engage with both the patient and the computer [PDF] naturally.
Lee said she envisions a longitudinal curriculum, introduced in phases throughout a medical student’s education as their skills develop. First-year students would be introduced to the concepts of patient communication and the current literature on using electronic medical records. Second-year students would role play and critique each other’s performances during their clinical skills courses, moving on to more formal evaluations during their clerkships. The goal is to integrate the training into the curriculum as soon as possible before bad habits develop. “The earlier we can get them to think about patient-centered electronic medical record communication, the easier it will be for them as they become practicing physicians,” she said.
In 2010, the University of Chicago Medicine became the first hospital in the country to provide iPads to all of its residents. A later study showed that the devices made them more efficient and freed up more time for direct patient care. Lee said this provides an obvious opportunity to expand their curriculum beyond desktop PCs in exam rooms, as more physicians carry smartphones and tablet computers to record and review information for inpatient care. “There’s room to grow on this because we’re moving more to iPads and tablet computers,” she said. “Moving beyond the outpatient experience, we have to think about how we’re using technology in the inpatient world. You can bring it from the clinic visit to the hospital, and I think there are a lot of avenues for improving those interactions as well.”
Computers and mobile devices have altered all of our personal interactions, not just at the doctor’s office. Alkureishi said we should apply the same rules there that we do at home to keep our teenagers from texting during family dinner. “When you introduce a gadget, be it a PC or a computer on wheels or an iPad, you have to know when to turn it off and when to use it,” she said. “I think it’s a larger issue of how you use all these things and still be respectful, engaging and compassionate. You have to acknowledge its presence with the patient, but don’t let it dominate what’s going on in that room.”