| As far back
as you look, the history of science is rife with puzzlement over
the relationship between mind, spirit, consciousness, and experience
on one side, and body on the other. How to reconcile
the subjectivity of human life with the objectivity of science
continues to be a central issue of post-modern life, especially
when it comes to healthcare.
The objective scientific point of view, with its emphasis on the
body, got its biggest boost in American medicine when the Flexner
Report on medical education was published by the Carnegie Foundation
in 1910. This book-length bulletin led to codification in the
U.S. of the German graduate medical education model, with a heavy
emphasis on teaching by scientific researchers, in the classroom
and at the bedside.
Despite modern attempts to broaden the curriculum and the doctor’s
mind, nearly a hundred years after Flexner the hegemony of research-based
science has remained virtually unchallenged in medical training.
Still, the personal, unquantifiable experience of health and illness
stubbornly insinuates itself into the world of the physician,
sometimes in the most unlikely of places, like the radiology reading
room. I’d like to tell you about an amazing study, undertaken
by Dr. Yehonatan Turner, a radiology resident at Shaare Zedek
Medical Center in Jerusalem. He reported his findings at last
December’s meeting of the Radiological Society of North
America.
For the purposes of his investigation, Turner attached a photo
portrait to the CT-scans of some patients. He found that the interpretations
of those scans that also displayed an image of the patient’s
face were consistently more thorough than the interpretations
of the scans without photos.
In general, the specialty of radiology attracts people who cluster
toward the data-driven end of the spectrum that runs from touchy-feely
to analytical. These are doctors who have chosen to spend the
bulk of their professional time with images, instead of with flesh-and-blood
patients. At work, radiologists mostly inhabit darkened rooms
with multiple, high-definition computer monitors, a dictation
gizmo, and little else. They strive to be as objective and thorough
as they can be. And still, having an image of the patient’s
face appears to help the coolly dispassionate radiologist to do
a better job.
I had this study in mind when a non-physician colleague asked
me what I think about the electronic medical record (EMR). Given
that the federal stimulus package includes $18 billion for development
and installation of EMRs throughout the healthcare system, this
is all of a sudden a more urgent question than it used to be.
Over the years I’ve been a huge proponent of harnessing
information technology in service of better healthcare, having
even published a couple of books about it. What we expect of the
modern doctor has long been impossible without an automated system
for keeping track of all the things – from drug interactions
to the attributes of uncommon diseases – that ought to be
at every clinician’s fingertips for every patient encounter.
Yet, neither I nor the vast majority of my colleagues has anything
like the information system we really need to provide the absolutely
best care, based on the best scientific evidence, to every one
of our patients at the time we see them.
I have railed for decades at the average doctor’s lack of
immediate access to critically-important, well-organized information.
So, I surprised myself with my answer to my friend’s query
about the EMR. I opined that the electronic medical record is
not yet ready for universal roll-out.
First, the problem of standards must be solved so most electronic
medical information systems can talk to each other. Even an institution
that brags of having the best, most comprehensive EMR will be
missing a large chunk of data that reside in other institutions’
computers, necessarily presenting a dangerously incomplete picture
of many patients. A significant share of the $18 billion is supposed
to go toward developing, disseminating and enforcing standardized
ways for medical information machines to communicate with each
other, which ought to help.
There is a deeper problem that makes the EMR still unready for
universal application. By interposing a computer monitor between
patient and doctor, so much may be lost if the result is to reduce
the conversation to filling in an electronic template so as to
generate quantifiable, codifiable, digital data. However badly
medical training may have damaged our ability to listen, most
of us doctors still do elicit and use our patients’ stories.
We mine these tales for data. We also depend on conversation to
develop the all-important therapeutic relationship, based on mutual
understanding and trust.
Human stories are told in idiosyncratic natural language, which
no computer program has yet come close to “understanding”
well enough to reliably turn narrative into data, let alone to
support a human relationship. An EMR risks losing the story, the
understanding, and the relationship when it leads doctors to use
a checklist to find out what’s really bothering a patient
instead of asking a few open-ended questions.
Eventually, the puzzle of EMR standards, as well as other technical
issues like usability and efficiency, will be solved. It will
take leadership, organization, time and money. However, nobody
has a clue yet about how to fix the deeper problem of story versus
data. There is no “killer app” on the horizon that
will do justice to both subjective and objective.
I plan to write another book one of these days about information
technology and medicine. That volume will be as much about what
electronic systems cannot do as what they can. The central theme
will be to examine how to employ these wonderful gizmos to do
the rote things that they do best so as to free health professionals
to do what we do best, which is to be healers.
Patients’ stories and their faces will always be crucial
data to a healer. I expect it will be a long, long time before
a machine can extract real meaning from a patient’s illness
narrative, let alone appreciate what there is to learn from a
picture of her face.
Marc Ringel has spent the majority of
his career as a family doctor working in rural communities,
including the last 12 years in Brush, Colorado. He has
written extensively, for lay and professional audiences,
about rural health, medical informatics and healing.
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