Contributed by OntarioMD Peer Leader Dr. Yves Raymond
Recently, Newfoundland physician Dr. Thomas Hall contributed an opinion piece to CanadianHealthcareNetwork.ca, the online home of The Medical Post. Hall’s article – which can be read here (if you’ve registered for a Canadian Healthcare Network account) – argued that while EMRs are useful for connecting health care databases and analyzing patient data, using them during patient encounters risks the doctor being seen as distracted and lacking empathy.
I commented on the website that I find it interesting that we’re quick to blame technology when, in fact, it is how the user chooses to use the technology that is the real issue. In my comment, I also took the liberty to rewrite Dr. Hall’s article substituting paper charts for EMRs as evidence that his arguments could still be made if the medium were paper rather than EMRs. My version is below. Leave a comment below this post to let us know your take on this important issue.
Paper charting no doubt helps remember what you did, but what do they do to the more subjective nonverbal parts of our patient encounters in office?
Over the last number of months, I have been talking with both psychiatry colleagues in Newfoundland and with staff at the British Columbia Psychiatry Association about their thoughts on paper charting in a family physician’s office. Generally, they felt, and I agree, that paper charts in a physician’s private office as a place to write notes after an undistracted face-to-face patient encounter is potentially helpful. However, in my informal conversations with these physicians, they all expressed serious concerns about the possibility of being distracted and the perceived lack of empathy that may arise from their use of paper charts in the office while examining a patient. This is a serious problem, as most family physicians use paper charts in their exam rooms while seeing patients.
Also problematic is that a family physician’s day is approximately one-third to one-half filled with some components of psychiatric care. I often ask physician colleagues the question: “What do you think of a patient who checks their agenda during their appointment?” Almost exclusively physicians answer with words such as annoying, wasting my time, rude, or with even more intense expletives. This is just a normal human reaction when we think our time is being wasted or we’re not being taken seriously. We physicians have to be aware that the reverse is also true for patients who perceive similarly in encounters where the physician is constantly looking at and writing notes into a paper chart.
Apart from the obvious perceived lack of caring and empathy that paper charts in patient rooms may exacerbate, there also should be serious concerns about what a physician might miss by being distracted by writing notes into a paper chart. A small enlargement of one side of a patient’s neck, clubbed nails, thinning hair, a small facial droop, a facial expression crying out for help from a patient’s partner sitting across the room, etc. These subtle things will undoubtedly be increasingly missed as physicians are pressured to enter more notes that often serves no purpose other than liability coverage and administrative information.
Paper charts will eventually be in every physician office in the country but the “leaders” in our profession, who are often too removed from complicated day-to-day front-line patient care, need to be more proactive about policies that will minimize these pitfalls. As an example, here is some advice from Nobel Prize winner Dr. Lown, author of The Lost Art of Healing:
“Healing is replaced with treating, caring is supplanted by managing, and the art of listening is taken over by technological procedures … Doctors of conscience have to resist the industrialization of their profession.”
Could rules be established by medical associations to suggest paper charting use be reserved to outside patient rooms? This would also require a potential increase in physician remuneration to manage the increased work that would result from extra notes entry at the end of the day.