Dr. Abraham Verghese on how computers steal time with patients

Troy Parks
Staff Writer
AMA Wire
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How can physicians maintain a balance between essential time with patients and all of the necessary clicks and patient data input required for modern practice? Abraham Verghese, MD, senior associate chair of the Department of Internal Medicine at the Stanford University School of Medicine and New York Times bestselling author, last week spoke to a group of physician leaders about the ritual of the physical exam and the need to reclaim time with patients while keeping pace in the 21st century.

The ritual: How technology is coming between physicians and their patients

The physical exam is a humanistic ritual that builds trust and creates the crucial bond between physician and patient—a bond that is at the core of quality health care, Dr. Verghese told physician leaders at the 2016 AMA State Legislative Strategy Conference in Tucson.

But with rapidly advancing technology, overwhelming amounts of data and burdensome regulations crowding into the exam room, what are the consequences when the computer screen steals physicians’ time from standing at the bedside of the patient?

As a practicing physician and teacher of medicine, Dr. Verghese has found his passion in making sure that not only his students but also the physicians he speaks with around the world remember that the ritual of the physical exam is the most important aspect of developing trust between patient and physician.

“There is something profound in listening to a patient and examining them thoroughly,” Dr. Verghese said.

“I hit on this method with patients while I was in Texas, where I would do the history entirely in one visit and not try to do anything more than hear their story. The average American physician interrupts the patient in 14 seconds,” Dr. Verghese explained as he described a particular patient visit in which he realized the ritualistic nature of the physical exam.

With this particular patient, “I held my peace for the entire first visit, and we agree that the physical would be in the second visit,” he said. “When they came in for the next visit, the patient continued to tell me history, and I decided to just launch into the exam.”

“I began my ritual as I always do with the hand, and a very interesting thing began to happen: This voluble patient began to quiet down,” he said. “I had an eerie sense that I had stumbled onto a primitive dance or ritual in which I had a role and the patient had a role. When I was done, the patient said to me with some awe, ‘I have not been examined like this before.’”

“We began with a partnership toward wellness,” Dr. Verghese said, “and it was only because I had earned the right by virtue of the exam.”

Patient time vs. computer time

Physicians in the audience were asked to consider the well-known painting, “The Doctor,” by Sir Luke Fildes, commissioned more than 120 years ago to capture the physician in that time. The painting depicts a physician sitting attentively at the bedside of a very sick child, where—as reported historically—he held vigil for two or three nights.

“[The painting] speaks to the Samaritan function of the physician,” Dr. Verghese said. “But what would this painting look like in our time?” Would the physician be facing a computer instead of the patient?

“The patient in the bed has become a mere icon for the patient in the computer,” he said, and physicians “are at the front lines wrestling with this.”

“We have an opportunity that we haven’t had in a long time to move the pendulum back in a direction that speaks to humanism,” Dr. Verghese said. Students must learn how to perform a thorough exam and “remember that patients have both a front and a back … a lot of juicy things happen between the dorsal of the patient and the bedsheets,” he said. The only way to get to those details is through a thorough examination.

And physicians want to reclaim the time for thorough patient exams. With more than one-half of physicians reporting that they are unhappy in their practices, Dr. Verghese said, physicians are fed up with systemic issues that are out of their control and are taking the lead in changing the system by speaking up.

Dr. Verghese highlighted what he believes are the four major consequences of losing time with patients at the bedside:

  • Patient dissatisfaction. “Patients aren’t happy with our [current] style of medicine, even though we have never been more potent in what we can do,” Dr. Verghese said. Reviving the culture of bedside medicine is a driving force behind physician efforts to remove burdensome regulations and technology that hinder interactions with patients.
  • Physician wellness. “There is a systemic issue that’s making doctors unhappy and driving them out of medicine,” Dr. Verghese said. “I think that the No. 1 cause of that issue is what I call the ‘4,000-clicks-a-day problem’—it takes 16 clicks to give a patient just one aspirin and 32 clicks to give them two.” These kinds of requirements are actively robbing physicians of time they would much rather spend examining their patients.

“Even though they don’t want to,” he said, “[physicians] are forced to spend a lot of their time right here [at the computer].”

  • Hidden medical errors. In a study published in the American Journal of Medicine, Dr. Verghese and his colleagues collected 208 physician stories and found that “the most common cause of [medical] error was simply a failure to perform the physical exam.”
  • Loss of ritual. “We engage in rituals to signal the crossing of a threshold,” he said. “An individual comes to see a physician to tell them things they would never tell their spouse … and then disrobe and allow touch, which would be considered assault in any other type of situation.”

The physical examination is a sacred ritual that has been developed and perfected over centuries, and physicians need to keep this ritual protected from extinction. “If we don’t protect and teach this ritual, it will die,” Dr. Verghese said. “At its very nature, the experience of medicine, the experience of being a patient, is very much a human experience—patients require the best of our science, but they don’t stop requiring the Samaritan function.”

“We need a better solution,” Dr. Verghese said. “The Stone Age did not end because we ran out of stones; we found something better,” he said. “Our present hyper-digital computerized age in medicine has to end because there are better ways that can take us back to the patient.”

Solutions physicians already have undertaken

With such imbalance between patient care and the lack of smooth functioning technology, physicians are actively seeking solutions that better merge technology with patient care.

  • The Break The Red Tape campaign gathers physicians at the grassroots level in order to form a coalition against burdensome regulations that complicate quality reporting and steal time away from patients.
  • Just this month, the AMA founded Health2047, a new integrated innovation company that will conduct rapid exploration of transformational solutions to some of the biggest challenges facing the nation’s physicians and the patients they care for.
  • Last year, the AMA partnered with MATTER, a health IT incubator in Chicago, to develop the AMA Interaction Studio at MATTER, which provides a space to create unique learning experiences and simulations using cutting-edge exam room equipment in order to build greater technology that streamlines work flows, saves time and allows physicians to spend more time providing quality care to patients.

Coming soon

AMA President Steven J. Stack, MD, sat down with Dr. Verghese for #AHealthierNation interview to further discuss the ritual of the physical exam, what it means to both patients and physicians, and the challenges physicians face in the current health care environment. AMA Wire® will share the exclusive content.

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Comments

Hello, Dr. Verghese! I know how important you believe the history and physical exam to be. I believe, also, the history and physical exam are of prime importance. I am grateful to you for your public comments like this to point this out to others. As physicians, we need to be reminded of the immense importance of the history and physical exam. Many people who are not physicians have to be convinced of this.
The physical examination should include a diagnostic triad consisting of detecting weakness of the fifth finger,paresthesias on elevation of the hand at times associated with the white hand sign and tenderness on thumb supraclavicular pressure,if not performed symptoms arising from the shoulder,neck,chest ,central nervous system and upper extremities will not be ascribed to Thoracic Outlet <br/> Syndrome .The FAIR maneuver should be performed in all patients complaining of lumbar pain or paresthesias of the lower extremities otherwise the diagnosis of Piriformis Syndrome will be missed
I have a question for you, Dr. Verghese. I am a PGY2 in Internal Medicine at a well-known program. Even though I agree with you completely, and indeed went into medicine for the purpose of meeting people at their root need and offering healing in whatever way I can, I instead am typing this response on the same machine where I spend almost all of my time, with minimal time left for the patient. Due to EDs and the way that American health care appears to be practiced now, I have no choice but to virtually remain tethered to this computer as I wait for another admission. Were I or my interns to spend the necessary time with patients, the backlog would fill almost immediately, and out list would be maxed out.<br/> Any thoughts? This is not what I thought medicine would be.
What is Dr. Verghese's book the article is talking about? The article doesn't name it and my online search has not found it. So, what is the title of the book?
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