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The Crucial 90% Missed by Doctors on Computers

A Q&A with Kevin B. Knopf MD, MPH, chairman of hematology and oncology at Highland Hospital in Oakland, California;

Q: A successful patient-physician relationship depends upon effective bidirectional attention and mutual understanding. Many patients and physicians believe that common current versions of mandated electronic health records (EHRs) severely impede that interaction, especially eye contact. How can a competent and caring clinical oncologist overcome that problem?

A: For all my faults as a doctor, and I’m sure there are many, there is one thing I think I do correctly, and that is I am never on a computer in front of a patient.

I hear from many colleagues that they can be efficient and personable while going back and forth from the patient to their electronic health record (EHR)—and it is true there are various levels of skill here. However, none do as well, in my opinion, as a computer-free patient environment. I say this from my side as a patient having seen dozens of doctors myself—nothing compares to a doctor who spends all of their time looking you in the eye and interacting face to face. This human contact costs nothing, and yet is so vital.

I’m hardly a Luddite; from my side as a doctor the math is infallible here: approximately 90% of all human communication is nonverbal, so if I am typing on a computer I’m only processing 10% of what is going on and my clinical efficiency drops accordingly. I’m convinced that this 90% is important not just for healing the patient; the way questions are answered and interpreted subtly can allow me to order fewer unnecessary tests and be a more cost-effective doctor.

In oncology many of the discussions veer into existential and religious domains, and this can’t be done except on a very intimate level. My greatest enjoyment in clinic are my patient interactions; for my own wellbeing, I hate to poison these with the EHR.

Some days it seems that the patient note in the EHR deteriorates to a “set of lies agreed upon,” particularly the review of symptoms and the physical exam, which is often templated and describes some Faulknerian version of the truth of what is actually happening.

In today’s world of “high throughput healthcare” designed to maximize relative value units (RVUs) and document in the EHR to upcode, it is the patient who suffers. And yet, it is the patient for whom we all go into medicine. I have done my own time and motion studies on this topic, and my current habit of reviewing the EHR in a separate room before I see the patient and then returning to that room to write the encounter after is more efficient than trying to go back and forth between the patient and the computer.

As a third-year medical student, now 30 years ago, the attending asked me to perform a history and physical on an inpatient in front of the entire team (gulp). I’ll never forget that afterwards he said, “you did a good job, but I want you to pull up a chair next time and sit down when you are talking to the patient.” This echoes the saying of the great oncologist Dr. Jamie Von Roenn: “Don’t just do something, sit there.” Indeed, there is a pleasure in the slowness of the patient encounter that most of us went into medicine to experience—and the EHR continually interferes with that process.

I recently spent about 10 days as a patient in the hospital—in three different hospitals—and different health care providers spent more or less time on a computer in front of me. The best came in my room and were computer free. In the end only one pulled up a chair and sat down to ask how I was doing—my friend the breast surgeon, who is a generation younger than me. I notice in her clinic she is an “EHR-free doctor” as well. Consider this a start.


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