When It Comes to the Physician-Patient-Computer Relationship, the “Eyes” Have It

Abstract

Among the greatest human achievements in history are the development and spread of spoken and written languages. The first English dictionary was published in 1604 and did much to codify the spelling, meaning, and usage of the written word which was notoriously varied and unreliable. Prior to that time, especially among the nobility, it was the spoken word that was considered both honorable and unquestionably trustworthy. From the seventeenth century onward, writing has been equated with literacy and has been the predominant means of codifying canons of evidence in the professions: medicine, law, religion, and education. Although speaking and writing are generally treated as different forms of knowing and doing, they intersect in fundamental ways in the physician’s examination room in the form of conversational sequences of questions and answers which are often simultaneously documented (typed) into the electronic health record.

This chapter explores the tensions created by the migration of computers and the electronic health record (EHR) into physician-patient conversations and the attention required on the part of the physician to be accurate and complete in documenting responses to history-taking questions while at the same time striving to remain patient-centered and relational. Drawing on fields as disparate as human factors engineering and animal ethology, a definition of “engagement” based on mutual eye contact, and “distraction” based on attention to the computer screen, is proposed. Analyses of videotaped ambulatory encounters using this definition demonstrate wide variability in engaged and distracted doctoring, with some physicians spending as much as 80% of the visit time looking at the computer screen, while others spend an equal amount of time making direct eye contact with the patient. Best practices for using the computer while maintaining a patient-centered focus are discussed.