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Eyes shift from patient to keyboard

For Dr. Michael Hochman, eye contact matters. For Dr. Michael Hochman, eye contact matters. (ISTOCK.COM)

When I began my residency last year at the Cambridge Health Alliance, I was thrilled to discover that I would be using a computerized medical record system. Computerized medical records - which are now used by about half of Massachusetts physicians and a growing number of doctors nationwide - are truly revolutionizing medicine, allowing doctors to chart patient information more safely, effectively, and legibly than ever.

Although the computerized system has proven to be a huge help, I have confronted an unexpected challenge: Despite repositioning the computer in every imaginable way, I often find myself making more eye contact with the screen than I do with my patients. It is simply more difficult to face a patient while typing than while writing.

When I ask my patients whether the presence of the computer bothers them, most are understanding (though one pugnacious older lady told me that my face looks better from the side anyway).

Still, a growing body of research is showing that computers affect the dynamics of the doctor-patient encounter. A study published earlier this year in the Journal of General Internal Medicine showed that about a quarter of patients felt as though computers reduced the amount of time their doctors spent talking with, looking at, and examining them. But just 8 percent felt that the computer actually interfered with the doctor-patient relationship. Interestingly, patients who saw resident physicians - doctors still in training - were more likely to express concerns, perhaps because experienced doctors are more likely to have well-established relationships with their patients.

In another study from 2006, doctors in Israel who had a computer in their office spent about a quarter of the visit looking at the computer screen (I probably spend at least this much time). The study also showed that the more time doctors spent typing, the less time they spent talking with their patients.

Computers also make the doctor-patient encounter a bit more routinized. In medical school when I used paper charts, I would collect information in a systematic but somewhat artful manner. For example, I would broach the subject of alcohol, tobacco, and drug use slightly differently with each patient. Now, my history taking has become more mechanical. I ask about alcohol, tobacco, and drug use by reading from a checklist of questions on the computer screen.

If used correctly, however, a computer can have positive effects on the doctor-patient relationship. In particular, the computer makes it easier and faster to read through the chart and find information about a patient such as his or her medication list, occupation, and the names and ages of any children. A 2005 study by researchers from Kaiser Permanente found that, after the introduction of a computer in the office, patients were more likely to feel that their doctors were familiar with their history.

Since computerized records are here to stay, the question is what can be done to ensure that computers will enhance - rather than interfere with - the doctor-patient relationship.

When I asked one of the more experienced doctors at my hospital how she deals with having a computer in the room, she said that she acknowledges the problem up front by apologizing to her patients for turning away from them. This helps her patients recognize that she is doing her best to communicate with them on a personal level even though she can't actually face them for large parts of the visit. She also makes sure to end all visits by turning away from the computer and toward her patient while going over everything that was discussed.

Additionally, patient visits may require more time when a computerized system is used - the opposite of recent trends. It is much more difficult to type while listening to a patient talk than it is to write. Also, because information is now more easily accessible, doctors may spend more time reviewing old notes. The upside of this, however, is that more can potentially be accomplished with each visit.

Finally, at a practical level, those sixth grade touch-typing skills are coming in more handy than ever. A few dexterously gifted colleagues of mine claim they can type their notes while maintaining eye contact with their patients. Perhaps remedial touch typing should be a requirement in medical school nowadays?

Like any new technology, computerized medical records affect patient care in both positive and negative ways. But overall, the balance is undeniably favorable.

Still, I can't help but feel as though my interaction with patients has become a bit less personal.

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