What Matters is How You Use it

At risk of sounding like a broken record (and sounding old by using this cliché), little about Sensible Medicine makes me happier than when a reader disagrees with one of us and writes a cogent retort. It is best when the reader disagrees with Vinay or John rather than me. 

Adam Cifu

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On July 14^th, Dr. Vinay Prasad published an opinion piece titled “When the Patient is in the Room, Stop Typing Your Note”. He argued that it disconnects the doctor from the visit, and keeps the doctor more engaged with a computer instead of the patient. These are valid points. The presence and importance of the computer and electronic medical record (EMR/EHR) adds an often unwanted and distracting third party to an intimate and personal discussion between provider and patient. However, in this day and age, removing the computer poses its own problems. 

Let me be clear: I hate that I type during my patient visits. I often say to patients (as I apologize for documenting while I get to know them) that I had sworn as a medical student never to be the doctor that types during visits—and when I first became an attending, I held to that. For the first few weeks, I typed nothing during visits. I talked to patients and examined them, finished the visit and grabbed the next patient. I only used the computer to put in orders, and I typed my notes at night at home. I very quickly realized that this was not a solution.

First, and foremost, I found that I could not remember key portions of the history and the minutiae of the neurological exam I had done on every patient. My notes became “short and to the point”, and also useless to my future self and to anyone else who might refer to what I had written to better understand the patient’s problem. When I later saw these patients in follow-up, I often had to re-do my initial consult as I did not have the required details documented. I also initially struggled to get many medications approved by insurance as I had not documented (to their satisfaction) all the previous drugs trialed by the patient. 

Notes do more than “cover your ass” or satisfy big corporations. They (should) leave a full history of an issue for both the patient and other providers, and can even be a place to elevate humanism in medicine. While Dr. Prasad is correct that many notes include fictitious exam maneuvers or out-of-date medications, notes can also include a patient’s preferred name, the name of the loved one they chose to bring to their visit, their housing situation, or their specific concerns—things I do not always remember at the end of a day of seeing 16 new people. By removing the computer from my encounter, I had inadvertently also removed some of my ability to connect at future visits.

Ideally, I would have a schedule where I could document in the time after a patient leaves the visit. However, given the limitations on visit time, to do this would dramatically shorten the amount of time I spend with patients. Since I prefer to allow patients the full visit they are slotted for, Dr. Prasad’s solution is instead that I “see fewer patients”. 

There is currently a 37,000-physician shortage in the United States, with projections that this could either more than double in the next 12 years, or (at best) shrink to only 13,500, depending on funding. If every physician saw fewer patients, this number would only increase. Additionally, my contract does not allow me the autonomy to choose to see fewer patients. Many providers like myself are employed in physician practices under practice management companies and do not have control over how many patients we see in a day. If I tell my administrators to “go to hell”, I suspect they will tell me to “go find another job.”(One could dedicate an entire Substack piece to this last paragraph. I will just move on.)

A better solution than telling all doctors who struggle with managing documentation to see fewer patients would be to introduce scribes (either in person or virtually), to allow the physician to devote all their attention to the patient without compromising the important aspects of documentation. Unfortunately, this decision is often not up to providers. Ultimately, this is a system wide problem that requires more than just physician engagement to solve. While I also hold myself and my colleagues to a high standard, it is not reasonable to only hold the physicians accountable, especially with solutions that are not available to the average provider. Those that employ us are arguably more responsible for creating an environment where providers can be efficient and patients can receive the care they deserve.

My solution has been to reintroduce typing to my visit. With an explanation, an apology, and mindful practice, I have succeeded. My patients have been understanding of the dilemma of needing to document during the visit and have still reported feeling well cared for. Sometimes the computer even adds value to the visit, allowing me to show patients their MRI findings, review guidelines with them, or find cheaper pharmacies for medications. Like with many tools, what matters is how you use it. 

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Danielle Howard is a general neurologist and neuroimmunologist at Tufts Medical Center in Boston.