Doctors, documentation, and the professional obligation: Has everything changed?

Technology, particularly medical technology, can seem both boon and bane. Certainly, there is no practitioner of the art of medicine that would want to do without it, and just as certainly, there exists no one without a legitimate complaint about it. Admittedly, this is not a new phenomenon, nor is it dependent solely on the complexity of the technology. Surely, when René Laennec invented the stethoscope, some senior physician somewhere complained that medical students were no longer pressing their ears directly to the chests of their patients; that “danged tube” was interfering with doctor–patient contact! Of course, for Laennec, that was the motivating factor when it came to the physical examination of young women—a degree of modesty that might be rare nowadays. (One wonders if it would be likely to trigger such a discovery in the present age.) So today, complaints about stethoscopes are mostly confined to the students’ lack of skill in using it for physical diagnosis, and questions about whether it is worn around the neck, or properly in the pocket of the white coat! The White Coat itself will not be subject to our scrutiny today; although it has practical and symbolic importance when worn by doctors, its role is more sacerdotal than technological—a thought we may revisit later.

More recently, we have seen explosive advances in technology, in areas such as diagnostic imaging, endoscopy, and minimally invasive surgery. They have delivered dramatic and welcome advances in our abilities to diagnose and treat patients in almost every specialty area, reducing error and improving outcomes. Of course, there are always potential downsides, such as overuse and the upward pressures on medical costs. On the whole, however, such advances have been welcomed by the profession with the same marvel and enthusiasm as by the lay public.

The same cannot be said for the advance of the electronic health record (EHR) or the electronic medical record (EMR), terms which are used interchangeably. It has created issues that seem both novel and troublesome, and prompted the request that I consider and address them, relative to our role as Catholic physicians. We have already seen that every new technology can have pros and cons, benefits and burdens—so what is the upside and what is the downside to this EMR or electronic health record?

The path to technology is also often paved with good intentions. In this case, the problems that the EMR tries to address are real. Unavailability of patient medical charts and old records, illegibility of the entries in these charts, and gaps in the format of histories and physicals, as well as errors in medication orders—all could be cured by a universal and properly functioning electronic medical record—and I am fully confident someday this will happen. Unfortunately, that day has not yet arrived, but nevertheless, we must deal with the undisputed and mandated arrival of the EHR. So we are dealing with not one EMR, but multiple EMRs and EHRs. They do not deliver on all their promises yet. They do not all talk to each other. Worse yet, they do not speak our language, but rather we have to speak theirs. We must deal with mastering one, or several, new systems for the clinic and hospitals in which we work. We spend up to 20 percent more time in data entry and record completion. But perhaps the biggest problem, for doctors and patients alike, is the entry of a third party into the exam room, the computerized record maker.

These complaints are voiced not only by the older white-haired troglodytes such as myself, but also by younger doctors. A recent Rand Corporation study (Friedberg et al. 2013, 33–7) shows that the majority of physicians are dissatisfied with their EHR systems.

According to the incoming president of the AMA, Steven J. Stack, M.D.:

Most electronic health record systems failed to support efficient and effective clinical work. This has resulted in physicians feeling increasingly demoralized by technology that interferes with their ability to provide first-rate medical care to their patients. (AMA 2014)

The complaints of physicians are myriad, and not unjustified. The complaints of patients are focused primarily on the transfer of attention from woman or man to machine during the clinical encounter.

Patients value the attention you give them during an office or hospital visit. In fact, it's often the only time someone focuses on their physical and psychological needs. It's not surprising to hear them complain about having to share you with a third “person” in the room. Taking a patient history while sitting in front of a laptop, filling out check boxes, and navigating drop-down menus often forces doctors to pay more attention to the screen, than to the patient sitting in front of them. Patients notice that. (Cerrato 2013)

So, is this a new problem, the unintended result of new technology? Clearly, the answer is yes. Are there possible remedies for the challenge?—Again, yes, and I will presently mention some. But first, let me tell you why I think this challenge is more important, more fundamental, than it might seem at first. I think it reaches down to the root of the question, “What is medicine.” Or, more properly, “What is medicine for?” Because it directly impacts the doctor–patient relationship.

Medicine fundamentally is a healing art, a healing profession. What do we mean when we say “profession”? Does it describe only those who do something for money? Many things are done for money, some useful, some shameful. But the medical profession, like the other so-called learned professions, requires more. Traditionally professions have been marked by their specialized body of knowledge applied for the good of others, and by their self-regulation, their code of ethics. In the application of that specialized expertise, the focus must be on the good of the patient in all we do. This is the oldest and most sacred duty of physicians, preceding even the principle “In the first place, do no harm.” Medicine involves doctors and patients, not providers and consumers of health care, not insured lives. The words we use have meaning, and implications for our professional interactions. The act of medicine involves the patient in need of healing, who is suffering from all the existential circumstances of illness: the lack of well-being, the assault on bodily integrity, and the dependence on others for a healing act. In response to this, there is the physician who makes a profession, an offer to help. Most people recognize that in taking an oath at our medical graduations, we have entered the profession. What must be remembered, and what was emphasized by my mentor and predecessor Dr. Edmund Pellegrino, is that this same act of profession is an integral part of our daily practice (Pellegrino 2008). When we enter the patient's room we say something like “How can I help you?” This implies that you have developed the capability to help and are putting that in the service to your vulnerable patient. You are professing both the competence and the willingness to act in the patient's good. This profession, and its accompanying actions, are fundamental to the core of the medical profession. They are symbolized by the pledge of the professional, every bit as much as they are symbolized by a stethoscope or a white coat. The white coat itself began as a tool of the trade, both a protection for the doctor and a pledge of cleanliness to the patient. In the present age, it is useful for the carrying capacity of its large pockets, but maybe most important as a sign of the professional role. As I said, that role entails a pledge of competence and the promise to act in the patient's best interest. Achieving and maintaining competence involves a lifelong effort. Of equal or greater importance is that dedication to the best interest of the patient. It is a pledge of altruism, although not absolute; it is a pledge of the effacement of self-interest. This pledge has consequences. It affects us when we answer that call in the night; it affects us when we prescribe tests and treatments that are precisely needed by our patients, no more, no less, despite the possible economic advantage or disadvantage to ourselves. The concept of putting the patient first has had a recent and dramatic demonstration of those age-old values. As we all know, an epidemic has been raging in the west of Africa. Facing epidemics is nothing new for the profession of medicine; the black plague, cholera, the Spanish flu, MERS, and HIV have all exacted a fearsome toll in history and in present times. Indeed, this is not even the first Ebola outbreak. However, in its extent and in its death toll, which is expanding exponentially, it presents an exceptional challenge. It is remarkable, and a credit to the healing professions, that this challenge has so frequently been met by physicians, nurses, and other healthcare workers native to the affected countries, as well as volunteers from abroad. Ebola has caused justified fears in Africa and unjustified fears in our country. People are scared because it is a scary disease. It is scary because it can carry a mortality rate of 50–70 percent or more, it is highly infectious to those coming contact with the critically ill patient's bodily fluids, and there is no proven prevention or cure. Nevertheless, we have seen medical professionals step up to fill the need for care, at no little risk to themselves, both in West Africa as well as in this country, as demonstrated by the recently infected nurses in Dallas. Now we must consider how we all might respond if one of these patients was to present in our clinic or hospital. Will we serve their needs, protecting ourselves to the fullest extent possible, but still accepting a deadly risk? Or, as some have suggested, should we offer these patients only minimal support, such as IV fluids, but avoid the exposure caused by blood drawing, invasive procedures, or more advanced support by denying their use to Ebola patients? Should the criteria be the possibility of benefit to the patient, or the need to protect medical personnel, or some balance between the two? And if we propose a balance, how do we achieve it?

The best answers to these questions will likely come from public health experts, intensive care physicians, as well as ethicists. What do we look for in those who would guide us in such morally challenging decisions? The most we can hope for, in this and any medical situation, is a physician of good character, one who accepts moral responsibility for care decisions and their outcomes, for competence, and for compassion toward the patients. Compassion goes beyond sympathy—compassion comes from the Latin meaning “to suffer with.” The physician capable of doing this recognizes that we are all members of the moral community bound together by mutually shared commitments, and focused on the good of our patients. Those physicians who share in the Catholic faith have the added advantage of an understanding and an example of how to approach the suffering patient. With Christ the Healer as an example, and Catholic social teaching as a guide, we understand the need for preferential option for the poor. We understand the need to share in the sufferings of our patients, as our patients are sharing in the sufferings of Christ. We understand that in the care of our patients, the extent of our generosity and altruism can never surpass the extent of God's gifts to us. This is certainly crucial in the dramatic and even life-threatening circumstances of an epidemic. However, most of us in this room will never treat an Ebola patient, will never be faced with the risks of an epidemic. What then are we to make of our present professional circumstances, and how do we bring our faith to bear on them?

In the present day and age, and in our country, there is no question that changes in medicine are occurring, and barreling down on us at top speed. There are plenty of overarching macroeconomic forces unsettling doctors—a sluggish economy, uncertainty about the impact of the Affordable Care Act, and the rise of narrow provider networks, just to name a few. But as we noted at the beginning, these big picture stressors often take a backseat to the everyday headaches that fill a physician's long days. We are pressured to overschedule in the face of more complicated clinical care and patients that tend to be older and sicker. Monitoring and documenting care has become more complex, as a result of increased regulation, quality indicators, meaningful use, medical home criteria, and other requirements. It is not just about doing the right thing for your patients. It is about proving to someone else that you have done the right thing. And as we have already noted, at the top of this list are the roles of the EMR or the EHR—does it bother anybody else that they cannot even seem to settle on a name for these electronic records? Is it any wonder that 40 percent of physicians now admit to experiencing symptoms of burnout.

Other studies have linked stress and burnout complaints directly to the level of EMR functions required in the workplace (Babbott et al. 2014). As the required time for documentation increases, less time is available to spend directly with the patient. This is exactly the wrong response, this is what we cannot allow to occur. If we allow these circumstances, these objects, to distance us from our patients, we will begin to depersonalize them, reducing them to data entry into our computers. How do we remind ourselves of how wrong this is, how it fails to fulfill the promises we made on entry into the profession? There are many ways that we can bring ourselves up short, to bring a brief halt to that runaway train that threatens to become our professional life. I know colleagues who stopped at the door of the patient room each time before they enter, and say a brief prayer. Especially when pressed for time and dealing with a difficult patient or family, I have found it helpful to remind myself who we are really serving. The ancient Greeks and Romans loved fables where the gods descended to visit mankind in disguise. This would reveal the character of those they visited, because they always appeared as the old, the frail, the poor, or the vulnerable. Those who treated them with courtesy and respect were rewarded accordingly. So were those who treated them with disdain and disregard. We have no such fables in our Scriptures—we have something more powerful and potentially more frightening. We have Christ telling us that however we treat the least of our brethren, we are treating Him. Imagining that presence in our examining room would make it hard to pay more attention to a computer screen.

This does not resolve all the issues with the EHR, of course. I am neither a computer expert nor a time management expert—those who are have suggested various solutions, some more feasible than others: these include completing the record later, involving the patient in entering and evaluating items on the screen, and positioning the computer so that you do not divert your eyes from the patient or turn your back to her or him. Some practices have been able to employ scribes to do the computer entry while the physician takes care of the patient. DragonWare, or other dictated computer entry devices, can also serve a useful function for some.

In the final analysis, these are just tools to deal with the problems presented by other tools, i.e., technology. They will not solve the most fundamental challenges to the profession; these answers must be found within the profession itself. Once the problems of an EMR are managed, other issues will inevitably arise. Our response to these future issues will require more than a technological fix for the profession to survive and flourish. We must, both individually and collectively, find within ourselves the character, the values, and the virtues that represent the best of a Christian physician. All professional medical codes are built on a three-tiered system of obligations related to the special roles of physicians in society. In a descending order of ethical sensitivity, they are observance of the laws of the land, observance of rights and fulfillment of duties, and, finally, the practice of virtue (Pellegrino and Thomasma 1988). We are, and will be, facing challenges more daunting than the technological imperative. Observance of the laws of the land may become less of a given in our practices. Our increasingly secular society not only tolerates challenges to an ethic of life, but attempts to require physicians to adopt these attitudes and practices. From abortion, to the manipulation and destruction of embryos for research or IVF, to the contraceptive mentality, to the disregard, devaluing, and finally destruction of the lives of the disabled or vulnerable, as seen in the move for physician-assisted suicide and euthanasia, all of these threaten to move from a position of toleration to a requirement of practice. What will the physician in all good conscience be able to do, and how will he or she be able to respond? To say that there are no simple answers is an understatement; to say that there are no answers at all is a falsehood. I believe that the answers will be found, as they always have been, both in the highest ideals of our profession, and in the guiding tenets of our faith. It is our duty to delve deeply into both, so as to be prepared for all those challenges, ranging from the profoundly annoying, such as an EMR, to the profoundly threatening to the practice of our profession, as well as to the practice of our faith. I say this in fullest confidence, knowing that we do not have to face these challenges alone. That thought sustains me, and makes me proud to be both a physician and a Catholic. It is said that the more things change, the more they stay the same. I am grateful to belong to both a faith and a profession for which this is undoubtedly true.

Biography

G. Kevin Donovan, M.D., M.A., is Director of the Pellegrino Center for Clinical Bioethics and Professor of Pediatrics at Georgetown University Medical Center.