Physician Attention Focused on the iPatient: Bedside Diagnostic Skills Deteriorate

According to one prominent physician, Dr. Abraham Verghese, electronic records and our sophisticated diagnostic tools are causing physicians to increasingly focus on the electronic records and diagnostic images (i.e., the iPatient) and ignoring their flesh-and-blood patients (see: Treat the Patient, Not the CT Scan). Put another way, we are treating the iPatients rather than the physical patient. Below is an excerpt from the article:

[The expanding reliance on electronic medical records] creates what I call an “iPatient” — and this iPatient threatens to become the real focus of our attention, while the real patient in the bed often feels neglected, a mere placeholder for the virtual record. Imaging the body has become so easy (and profitable, too, if you own the machine). When I was an intern some 30 years ago, about three million CT scans were performed annually in the United States; now the number is more like 80 million. Imaging tests are now responsible for half of the overall radiation Americans are exposed to, compared with about 15 percent in 1980. With that radiation exposure comes increasing risk for cancer, but what worries me even more is that this ease of ordering a scan has caused doctors’ most basic skills in examining the body to atrophy. This loss is palpable when American medical trainees go to hospitals and clinics abroad with few resources: it can be quite humbling to see doctors in Africa and South America detect fluid around patients’ lungs not with X-rays but by percussing the chest with their fingers and listening with their stethoscopes. Of course, we still teach medical students how to properly examine the body. In dedicated physical diagnosis courses in their first and second years, students learn on trained actors, who give them appropriate stories and responses, how to do a complete exam of the body’s systems (circulatory, respiratory, musculoskeletal and the rest)....But all that training can be undone the moment the students hit their clinical years. Then, they discover that the currency on the ward seems to be “throughput” — getting tests ordered and getting results, having procedures like colonoscopies done expeditiously, calling in specialists, arranging discharge. And the engine for all of that, indeed the place where the dialogue between doctors and nurses takes place, is the computer.

As I contemplate the idea that our young physicians are focusing on what Dr. Verghese calls throughput, I think that two factors contribute to this mindset. The first is the skyrocketing cost of inpatient care and the second is the use of length-of-stay (LOS) as a measure of hospital quality and efficiency. A decreasing LOS has been used for more than two decades as a key measure of effective hospital and patient management. One of the reasons why an increasing share of inpatient care is delivered by hospitalists is their emphasis on LOS at the direction of the c-suite in hospitals. It is thought that these salaried physicians devote more attention and energy to earlier patient discharges (see: Resource Utilization: How Hospitalists Add Value to the Bottom Line). I don't see this trend reversing in the immediate future because inpatient care is so expensive and there is pressure to reduce the cost of care.

The reason why doctors favors the iPatient (i.e., the body of clinical information characterizing the patient) over the physical patient is obvious -- such a focus provides the most efficient way to arrive at a diagnosis and a therapeutic plan. This, of course is a source of angst for the patient who is looking for more personal interaction from his or her physicians. For me, there is only one way to solve of this dilemma -- the greater use of computer algorithms integrated into the EMR such that the ordering of diagnostic tests, generation of the diagnosis, and the development of a therapeutic plan are managed in the background. This frees up the physician to pay more attention to the emotional and informational needs of the patient.

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[Dan Farkas]

Excellent article and one that causes great concern. In an era where we are interested in limiting "runaway" healthcare costs, the use of imaging vs. the humble stethoscope, as discussed is the article, is telling. With next-generation sequencing (NGS) on the horizon, and the huge amounts of data such technologies generate, will a record even fit on an iPad in the near future? So I throw out the question: are new genomic technologies, specifically NGS, going to generate so much data that our IT-based storage capabilities will be inadequate? Will a patient have to carry his/her sequence on an external Tb hard drive as (s)he moves from job to job and physician to physician?