My doctor is a computer!


There was no mistake, but a bad thing has happened.  Despite the best efforts of the doctors, Bob’s wife is very sick.  Due to a rare side effect of treatment, her liver is failing.  Bob believes this could have been prevented. He is very mad.

“When we go to see the doctor, he stares at the computer,” says Bob. “He does not look at us.  Most of the time, the doctor is not even listening to us. He just sits there typing at the keyboard, gaping at the screen.  If he had been listening when my wife talked about the pain, then he would have stopped the drug.  Then her liver would be fine. She would be OK.  All you doctors have become nothing but computers.”

Now here it gets interesting.  After I listened carefully to Bob and sat with him at his wife’s bedside, I decided to check “the computer.”  There in the doctor’s records I saw a long discussion and analysis of the problem with her liver. Quite opposite of ignoring her, her doctor had listened, had changed therapy and was watching her liver carefully.  Sadly, despite the change, her liver had gotten worse. The problem therefore, was not that the doctor was not listening.  He definitely was.  The problem was that the computer had stopped him from communicating.

It is strange to think that a system of information and data exchange, which allows you to communicate with anyone around the entire world, interferers with connecting to the person right in front of you.  We see it constantly as cell phones, Ipads, computers and even that “old” obstructer the television, get between us.  At the time we need to communicate most desperately, electronics can block that most human connection of all, the physician – patient relationship.

Let us be clear.  Multitasking is a fallacy.  We can only do one thing at a time.  We cannot drive and text.  We cannot talk on a cell phone and listen to our mates.  We cannot watch a game on TV and discuss finance with our partners.  Most importantly, we cannot focus fully on a patient and a computer at the same time.

Now, I am 100% committed to full computerization of the medical community and exam room.  The future of quality, medical safety, and cost containment can only come from full implementation of Electronic Medical Records (EMRs) with system wide analysis and the assistance of artificial intelligence.  However, right now is a tough time.  We need to figure out the new social mores’ and workflows, which will allow physicians to communicate with patients and with the electronic world.

Therefore, both physicians and patients need to learn new habits and establish slightly different norms for the doctor visit.  Patients must understand that for moments the doctor will look at the computer instead of directly at them, and not be offended.  Both doctors and patients should turn off their cell phones.  Doctors need to take time during each visit to look patients in the eye, instead of ogling the monitor.   Exam rooms should be set up to make this easy. It is one thing to type information (smoking history, dates they of medicines, type of surgery…) and another to ask tough personal questions while absorbed in a monitor. Doctors must never teach or give advice while at the keyboard. We must turn, see and touch our patients.

As Bob’s experience shows, even if a physician is doing the correct thing and paying close attention, the patient sees only an uncaring man staring at a screen.  The direct contact of the physician – patient experience is still vital.  Medicine is about people helping people and the cold interaction of the supermarket checkout line, will not suffice.


  • michele menditto
    My surgeon recommended I met with you in 2004 when I was diagnosed with Breast Cancer (LCIS) after a bout with DCIS and radiation treatment years earlier. He wanted me to obtain a second opinion about my options. I had thoroughly researched my options and knew I wanted to partner with my doctors to overcome my disease. You were prompt, shook my hand firmly and asked me to explain what I knew about my disease and how I felt about my options. You did not take any notes but looked me straight in the eye and waited until I was finished. You agreed with my assessment and knew I fully understood my decisions. I am sure you took notes later but looking me straight in the eye made me feel very secure. Thank you for being a caring doctor who made me feel empowered about my decision.
    • James Salwitz, MD
      Thank you very much for your kind comment. Whenever I write something about how doctors should behave, I feel guilty about making recommendations that I am not certain I do correctly all the time. Your reassurance says that at least sometimes I am on the right track. Stay healthy, jcs
  • Laura
    A few years ago I saw my primary care doctor about shoulder pain. He sent me for an MRI and I subsequently got a letter saying the results were normal. But my shoulder still hurt, so I asked for a referral to an orthopedist. This doc showed me, on that very MRI, my tendinitis, and we began treatment. When I saw my primary care doc again I asked him about that letter. He pulled up on his computer the letter he had received from the radiologist. There was an entire paragraph about the tendinitis, but the last paragraph was a single sentence stating that the scan was unremarkable. "How is it unremarkable," I said, "when he had just remarked about it." But my doctor was embarrassed because his office had regarded only that last sentence and sent me the letter saying that the results were normal. I suspect that the last sentence was an automated thing that no one realize they had to turn off, and that my primary care doc's letter was also automated, based on that sentence. I am filled with confidence, let me tell you. Computers are great and wonderful things - I have used them in the chemistry lab from the late 80's on - but they are only tools. People don't understand their limitations sometimes and that's a big problem. I get those automated letters "your blood work is normal" and now I call and ask for the actual results.
    • James Salwitz, MD
      Excellent point. One of the real risks of computer based systems is that doctors will use them as short cuts. A good example is that in our office all our patients' labs come back in two computer files - 1)normal 2)abnormal. There is a default button on the screen which we can use to clear all the "normal" labs. But, what if I am taking care of a patient who has a new problem and I ordered the test to try and get an answer. In that case a "normal" test is a valuable clue, which requires action - I need to take another look at the patient and possibly order another test. But, if I just clear all the patient's labs as normal, I may not even think to re-contact the patient. It is a new world with different rules and we all need to be aware of its strengths and pitfalls. Thanks for your comment. jcs
  • BIll Wickart
    Jim, let me propose the other side of this relationship. I agree that doctors will, in some fashion, need to change their relationships with the data provided. However, I see a huge problem in that the computer systems are not fitting easily into your established routine. I see this as a software failure. You people had a professional-client relationship that was working for all involved. The software people brought you "easy" access to basic data, but failed to solve *your* problem of all-around improved care. Rather, the system is cumbersome enough, as evidenced by your apt use of the word "tethered", that the system's very wealth of data actively interferes with what *used* to be a working system. I believe that you, personally, have an understanding of software that is somewhat more informed than average, even in your peer group. So I ask you: what can we software monkeys do to become a better support for you on the front lines? How would you want to access this information from your exam room or your personal station? What display mechanisms would you want? What choices and interaction? If you care to contact me individually, I'd be happy to dig a tunnel through my corporate structure (which we're encouraged to do) and find someone appropriate to take your input and work on turning it into reality. I know that this is a big project, but we have to start somewhere, before we lose the prime healing weapons: the patient herself.
    • James Salwitz, MD
      You are %200 on target. The data input / output interface is a horrendous rate limiting step in the implementation of health care IT. Until this obstacle is solved, EMRs will never reach their potential. I will indeed reach out to you. It is a project that can change all of medicine. jcs
  • Bill Wickart
    Vacations slowed commutations somewhat, but I believe I've tunneled to the proper project within my company (open-door policy is nice). I forwarded links to your articles and the references you provided, along with my personal opinion of GUI (graphic user interface) design: so far, the industry has targeted the doctor's left brain, rather than focusing on the *client*. I'm hopeful that this will get kicked to the proper people in just one more step. It's quite possible that they 're already working on the problem with some partner medical institution. If not, I'm hopeful that they'll incorporate this into their next round of project proposals.
    • James Salwitz, MD
      Very exciting. Please feel free to forward materials to my primary email address. jcs
      • Bill "Prune" Wickart
        It took me three widely-separated attempts (my delay, not Intel's) to find the right connections within our corporate web. I have just emailed Drs. Mandl and Kohane ("Escaping the EHR Trap") with the contact info for Intel's head of medical systems design. She is quite interested in getting their active, continued input into solving these problems, as her own research is in exactly this direction.
        • James Salwitz, MD
          Fascinating. Let me know if I can help. jcs
  • [...] As more doctors switch to electronic medical records, patients will insist on the computer being a tool to help, not an interference.  We will refuse to see people who make us feel like saying My Doctor is a Computer! [...]
  • [...] As more doctors switch to electronic medical records, patients will insist on the computer being a tool to help, not an interference.  We will refuse to see people who make us feel like saying My Doctor is a Computer!  [...]
  • great post. I agree with you and have linked to your post in my blog today.
    • James Salwitz, MD
      Thank you very much. An ongoing and transformational conversation. jcs
  • [...] a tool to help, not an interference.  We will refuse to see people who make us feel like saying My Doctor is a Computer! “WarmSocks” blogs at ∞ [...]
  • [...] Médica del Hospital Italiano este post sobre el tema, que rescata otras experiencias (de KevinMD y SunriseSounds) sobre este tema tan [...]
    • James Salwitz, MD
      Sono onorato jcs
  • barbara brandt
    I just had the worse physician visit of my life in a Clinic. I sat looking at the back of the doctor and she spent 90% of her time typing. She argued with me when I tried to tell her I had pain and where it was. I have advanced osteoporosis and I could not make any sense out of her statement. They seemed disconnected from the first visit. After 30 minutes into visit, she asked if I had my bone scan report. I had given that report to this Clinic 3 months early when I applied. They were actually going to give me an injection but somehow they lost info on that. I told the doctor I gave her the report weeks ago. As she now was looking at me, I realized that the report was on her computer screen behind her! I could not figure out what was going on. She was unfriendly. She was unhelpful. She was obviously annoyed that I was telling her something about pain. I was going to tell her about a car accident where I had lifted the driver out of the SUV because it was smoking and I was the only person tall enough to reach the women. That was the beginning of this horrific pain. The women was saved from the car with the help of another women. Then the fire department was worried about my leg because I had problems walking. But never got to mention it. This nasty doctor -- yes nasty -- told me to come back in 3 to 4 mnths, prescribed a med that was $180 and the fusion center at the hospital which was $1200. This was a low income Clinic! The message for me was to never go back. Now I have to find a dcotor and wonder why anyone would set up an exam room like this. Robots all!!!

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