In Stanley Kubrick’s classic film “2001: A Space Odyssey,” the survival of astronauts on a space mission depends on a computer, the infallible HAL 9000. HAL relates to the crew in human fashion and keeps them safe until the chilling climax when he decides to engineer their murder by sabotaging the ship’s life-support systems. It is the quintessential depiction of the erosion of trust between man and machine.
The medical profession currently faces the same existential crisis. Since being introduced into hospitals, computers have advanced medical care tremendously, but now they represent a serious threat to depersonalize the patient. According to a recent study in the Journal of General Internal Medicine, doctors in training currently spend only 12 percent of their time in direct patient care compared with 40 percent of time spent in front of computers. Moreover, this trend of reduced interaction with patients is growing worse.
It would be tempting to ascribe this development, like so much else in our contemporary culture, to a generational shift in attitudes. As one medical resident told The New York Times, “My generation is different because we can’t have the same relationships with patients as you did. We just don’t have the time.”
A nice, facile explanation, but this problem is hardly confined to young trainees. Virtually every attending physician I speak to, including some in their 70s, describes the unsettling number of hours they must spend in front of the computer at the expense of time with the patient.
Nor is this development limited to physicians. Today’s modern hospital furnishes nurses with portable computers to enter patient data, write notes and scan medications. Presumably more efficient, but unquestionably less personal. Nurses, like their physician counterparts, have become more high-tech, less high-touch.
The resident who spoke to The New York Times unwittingly fails to appreciate the twofold problem the current situation presents. First, to become proficient, a doctor or nurse must train all five of their senses, which the computer discourages. One must learn to observe by actually looking at the patient. Likewise, learning to talk to the patient, what to ask, as well as when and how, cannot be replicated by a software template of questions.
Hearing is also a skill that must be cultivated — it’s more than just listening to a stethoscope; it’s listening to what the patient has to say. Touch is important, everything from taking the pulse to palpating masses. And smell can be a means of diagnosis; there are even diseases that can be diagnosed the moment you walk in a patient’s room. Staring at a computer screen and tapping on a keyboard might approach but will never reproduce all these things.
But even more significant than acquiring technical proficiency is establishing human contact. The essence of the medical profession is showing a patient you really care by creating a personal bond — the manner in which you talk to them, listen to them, touch them sympathetically and make eye contact (tellingly, in “2001,” HAL’s lack of human emotion was portrayed by its electronic laser eye, which gave the astronauts nothing to make eye contact with). No one expressed the essential nature of human contact better than Sir William Osler, considered the pre-eminent clinician of the 20th century, who advised the young doctor, “Care more for the individual patient than for the special features of the disease. … Put yourself in his place. … The kindly word, the cheerful greeting, the sympathetic look — these the patient understands.” Contrast the 20th century Oslerian philosophy with the 21st century philosophy expressed by Secretary of Health and Human Services Kathleen Sebelius. In 2010, in Kaiser Health News, she wrote, “Over the last 30 years, we’ve watched information technology revolutionize industry after industry, dramatically improving the customer experience and driving down costs. Today, in almost every other sector besides health, electronic information exchange is the way we do business. A cashier scans a bar code to add up our grocery bill. We check our bank balance and take out cash with a debit card that works in any ATM.”
This analogy betrays a fundamental misunderstanding of the art of medicine in any century. Grocery bar codes and ATMs are efficient, albeit depersonalizing examples of technology affecting our lives. But the ideal goal of medical care is to be able to spend more time with and attention to patients, not less.
Bedside manner is on its deathbed. It can be saved only if the medical community, the tech community and the government address the proper use, and abuse, of computers in medicine. The alternative is that in the future patients will be citizens of a dystopian brave new world, where anyone may be able to see the doctor but the doctor won’t be looking at them.
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