Electronic health records may impede good doctor-patient relationships

I was giving a talk today, and at the end, someone asked me about an application he has on his phone that monitors sleep (it’s called Sleep Cycle). It reminded me that there is ever-growing potential for individuals to be able to gather data on themselves and, if they want’ use that data to improve their situation. Blood pressure and blood glucose monitors are other examples. In general, I embrace this sort of technology as I believe, on the whole, it empowers people and makes them less reliant on doctors and the medical profession as a whole.

However, as with most things, technology can have a downside too. In medicine, there has been a move towards individuals’ health records being held electronically. What this means is that when a patient consults a doctor, the doctor is not consulting notes written on paper or card, but those appearing on a computer screen. A recent study assessed whether or not this changed the dynamic of the doctor-patient relationship [1].

Specifically, the researchers assessed how much time doctors spent looking at each other. It turns out that the use of electronic records was associated with significantly less time during which a doctor was actually looking at their patient. Also, there was a tendency for patients to spend quite a lot of the time staring at the screen too, irrespective of whether they could see what was on the screen or understand what was written.

These findings suggest that the use of electronic health records may represent an impediment to the doctor-patient relationship and the best medical care. After all, good communication, which is generally aided by eye-contact, is the bedrock of good medicine.

Reading this research, reminded me of the countless occasions I have heard patients complain about their experience with a doctor and they have used the words: “And all he/she seemed to be interested in was his/her computer screen.”

As I say, I embrace technology. However, when it comes to medical practice, I am a bit of a traditionalist, I think. Call me old-fashioned, but I think that during a medical consultation, it helps for the doctor and patient to be looking at one another.


1. Montague E, et al. Dynamic modeling of patient and physician eye gaze to understand the effects of electronic health records on doctor–patient communication and attention. International Journal of Medical Informatics 2014; 83(3): 225-234

14 Responses to Electronic health records may impede good doctor-patient relationships

  1. A. Harfney 24 January 2014 at 10:31 pm #

    I agree with this! Recall one app’t when the MD did not even look at me – once. He did answer my questions, and I did not like his answers. Felt that had he even looked at me that it would have changed the dynamics!

  2. Zarayna Pradyer 24 January 2014 at 10:34 pm #

    If memory serves me correctly, I believe it was in “Medicine Unmasked” by Ian Kennedy (the chap latterly charged with trying to sort out MPs expenses) that he recommended that doctors consider the use of computer records. This was because thirty years or so ago, hand written doctor notes were notoriously difficult to read and probably to file accurately. He calculated that a more accessible patient history could be kept on-line.

    Obviously, he didn’t foresee that the doctor would give preference to the screen rather than the patient because: – the computer in-put is really a legal defence in case of trouble plus it is a doctor’s work sheet and usually, but not always, it is a patient’s record. Lastly, and I do sympathise with this, the screen is more interesting, controllable and certainly more pleasant and accommodating than a patient.

    Lastly, I wonder if there would be a different attitude if patients actually paid something, however nominal, at the point of delivery. Doctors might be reminded to be more courteous and patients might feel more empowered – not always but sometimes.


  3. Brian Fullerton 24 January 2014 at 11:53 pm #

    Last year I went to the GPs (as a last resort) due to a long running viral (I think) infection (hoping for blood tests, not DRUGS !!!). Never met this Dr before in my life but in less than 5 minutes of him mostly looking at the monitor he exclaimed totally out of the blue “YOU DONT LIKE DOCTORS DO YOU”. Go figure.

  4. Jack 25 January 2014 at 12:06 am #

    My G.P never looks at me. He sits side on, reading his screen. He also doesn’t touch me. Even when I had a throat problem he didn’t feel my glands. I am a very clean, well-presented person but I feel I always leave thinking I could have just as easily have had the consultation by email.
    Years ago my G.P was ill & an old retired G.P was brought in to cover. I was astounded by his approach. He got up when I knocked, knew my name, greeted me in a friendly, welcoming way and sat directly facing me. He looked carefully at me the entire time. He was decorous and sensitive and at the end I felt thoroughly satisfied, seen and acknowledged. He also cured a problem I had had for years. I will never forget him.

  5. Lori Miller 25 January 2014 at 1:01 am #

    My GP ordered a test for iron deficiency because of my pale skin (even though I made the appointment for something else) and a test for H. pylori from a touch test. Both the tests came back positive. He consulted the computer records, but wouldn’t have made such good diagnoses if he hadn’t set the computer aside.

  6. George Cooper 25 January 2014 at 11:11 am #

    Well done Dr Briffa! In Traditional Chinese Medicine the physician is expected to smell, observe, listen to and palpate the patient. A computer just gets in the way of this process.
    There’s no computer in my treatment room, just a lovely roll top desk.

  7. SueG 25 January 2014 at 2:30 pm #

    Isn’t this more of an issue about the quality/standard of doctors governed by their personna than a debate about the place of technology within a surgery setting? Some doctors appear patient focused and will interact with you whilst others place themselves on a pedestal and expect blind faith in their skills? I recently visited a GP who was interested both in what I was saying and finding answers and I left the consultation feeling I had been listened to for the first time in years.

    My first ever visit to a GP in that practice saw me walk in, be invited to sit and then the GP said absolutely nothing for several minutes, just sat and looked at me, leaving me feeling embarrassed and not a little bewildered as to what to do next.

  8. Linda T 25 January 2014 at 3:39 pm #

    the only part of my GP that I would recognise outside of the surgery is their right ear and nose tip as that’s all I see once I sit down. Apart from the fact that it’s very off putting talking to someone who’s only half listening (while they’re looking for a letter on the keyboard) it also seems very bad manners. maybe a typing skills course should be included in GP training?

  9. Barry Danser 25 January 2014 at 6:35 pm #

    You can’t blame the computer screen for the Doctors taciturn or unfortunate manner.
    You may instead blame the cost related problems that a doctor has to contend with.
    They have to pump that computer full of information make a diagnosis and put you out of the door asap.

    Firstly I have a trick or two
    1. never accept an alternative doctor I am always being told mine is not available so unless its something minor I stick to my guns.
    2.Write everything down you need to discuss and in some cases fax or post it ahead of your appointment. Doctor then has a choice to write up your notes in advance

    This saves time 1. He/she knows your history 2. You have prepped your doctor and are less likely to forget stuff.

    Oh and finally move your chair so you can’t see the screen and your doctor has to look away from the screen to see you. I normally place the chair to the side and slightly behind the monitor they are more likely to make eye contact.

    Finally some doctors are just SOB’s and there is nothing you can do with that and others are crap at using computers so they have to spend too much time inputting.

    Go figure!

  10. TJ the Grouch 26 January 2014 at 2:29 pm #

    Retired bone doc myself (before all this newfangled crap came on line). Went to see a specialist and, lo and behold, the man never so much as touched me. Needless to say, I never went back and didn’t get the tests he ordered done. Surgery (surgeon) comes from roots that mean ‘hand’ and ‘work’ respectively and not from “I’m looking at a screen and not at you”. I do admit that my handwriting stunk. I used to tell my kids that medical school included a semester of forgetting how to write. I don’t remember a single patient that I did not touch with my hands during an examination.

  11. TV John 27 January 2014 at 1:01 pm #

    It would be interesting to know how having notes on a tablet might affect that dynamic. It has all the convenience of computer notes, but you interact with it differently, more like paper notes.

  12. DrewTX 27 January 2014 at 9:30 pm #

    Sorry Dr. Briffa, I have to disagree with you and most of you commenters. The computers screens do not ‘get in the way’ – they are inanimate tools. If a Doctor CHOOSES to stare at a screen – rather then at the patient – then it is the Doctor that is at fault, not the technology.
    Paper medical records have NO place in modern society. It is terrifying to think that my medical records might be stored on paper in one location. What if there was a fire or flood? What if I want a different Doctor to quickly access my records? What if *I* want to access my records?

    Whether they are stored on paper, or on a computer, the Doctor still has to take take to read them – and that should take no longer on a monitor than it does on paper.

    If the Doctor stares at the records (wherever they may be stored) and does not interact with the patient, then they are a bad Doctor.

    Don’t blame the technology.

  13. Karen Harrison 29 January 2014 at 11:33 am #

    We have been pushed into the digital age and all our notes are on computer. However in my half hour appointment slots I spend 99% of the time looking at and talking to the patient. I read the casenotes before they come in and make only minimal additions while the patient is in the room. This is because if I was the patient I would expect to be looked at and spoken to. Am under a barrage of pressure to get it all done including inputting and letters in that half hour slot – but I tend to ignore it!

  14. Chris 30 January 2014 at 9:48 am #

    Commercial airline pilots spend so little time flying these days (the autopilot is generally in control) that it is now stipulated they must clock up significant flying time flying flight simulators. Irrespective of the fact that simulators help the pilots train for atypical situations and emergencies (and the case where instruments malfunction) the headline still conveys some significant irony. Pilots may seem decreasingly capable of flying a plane with use of the yolk, visuals, and the seat of their pants.

    There is no denying the arsenal of tests and results are an aid to diagnosis in family practice but what happens if tests are not so reliable as they are claimed or if the results that are returned are in some way atypical? The lipid profile test (the common test for ‘cholesterol’) doesn’t really report much, for example, and yet medical practitioners invest great faith in the capacity of the results to guide them in practice. Does the growing availability of tests, test kits, and increasing use of them mean doctors are decreasingly willing, or able, to diagnose by the seat of their pants, by which I refer to extensive training, ‘craft skills’ of consultation and examination, accumulated experience, and hard earned intuitive sixth sense?

    An increasing eventuality stemming from the information revolution (and several very informative blogs) is that some patients may be better informed about some conditions that are some GPs.

    The party line in medicine is that saturated fat and raised cholesterol lead to heart disease (via the pathway of causing fatty (or calciferous deposits called ‘atheromas’ in arteries) yet as far back as 1974 Imai and colleagues identified pure cholesterol is not at all atherogenic but cholesterol contaminated by oxycholesterols is. One of the three possible oxidised cholesterol, one named cholestane triol, is very highly atherogenic. Cholesterol does bot promote growth in atheromas (does not cause heart disease) but oxidised cholesterol may.

    I am actually very satisfied with the consultations I get from my GP but I do not visit that often – despite I am on record as being type-2 diabetic. I have huge respect for members of the medical profession whose involvement often save peoples lives, but family medical practice demands GPs must know something about so many conditions. Through researching diabetes, metabolism, and heart disease for myself it seems to me that the conditions GPs must operate under dictate (contrary to popular perception) that their knowledge must be spread a little thinly. If I placed myself in their shoes how would I feel?

    I think the conditions GP must work under; pressure to tow the party line, incentives to do so, peoples lives their hands, big-pharma-propaganda, too much literature, and a small but growing number of patients who might contradict something I’ve been trained to consider is true, and do so from a well-informed perspective, would have me feel decreasingly secure, unless I twigged that patients themselves can be a knowledge base to respected. Perhaps the willingness to fix attention on that screen is a sign of increasing feelings of insecurity, and placing more faith in it’s content, is a way of avoiding cognitive dissonance that the patient, or his/her symptoms, may convey. After all the screen and the data within cannot lie, its the patients history in full. (?)

    Incidentally, cholesterol guidelines are likely enforced upon commercial airline pilots with more zeal under medical rules that may be applied to them and their profession, and yet low cholesterol levels may associate with diminished visuomotor speeds (reaction times) [MF Muldoon & others]. So if you can glean the sense your pilots capacity to react to situations may be dulled because, in effect, his airline insists he must take statins to keep his (her) cholesterol within arbitrary (read ‘silly’ or ‘senseless’) limits, then you might be glad the autopilot has full control of a commercial airliner for most of the time.

    Our world provides many finite resources that cannot last forever, but we’ll never run out of irony.

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