Has the computer killed the conventional Doctor visit or provided the biggest opportunity for reform?

Does Decision Support Make Docs Look Dumb?” is a fabulous report by Gienna Shaw for HealthLeaders Media, and I think it’s all the evidence (if you needed it) that the current system of patients interacting with primary care Doctors in 100% realtime is a broken model.

Key points:

> “some patients are skeptical of docs who need a computer to help them make a diagnosis”

> “some physicians don’t want to be seen as being too reliant on technology”

> A 2008 study published in Medical Decision Making reported that patients “always deemed the physician who used no decision aid to have the highest diagnostic ability”

> James Wolf, Illinois State University’s School of Information Technology, reported that “tech-savvy undergraduate and graduate computer science students preferred physicians who rely on intuition instead of computer aids… …Patients object when they ask their doctor a question and then she or he immediately types in the question into their laptop and then reads back the answer. It gives patients the feeling that they just paid a $25 copay to have someone Google something for them… …Eventually, it won’t matter what patients think—EBM data and decision-support tools will be increasingly embedded into EMRs… …Patients won’t even be able to tell whether their doctor is using a computer in their diagnostic decision or not… …in that way, it will become more like the autopilot used on commercial planes. When we fly, we do not see what is happening in the cockpit, so we don’t mind that computers are actually doing most of the flying”

> Joel Diamond MD, a family Doctor in Pittsburgh, “Regardless of whether patients embrace decision-support tools, physicians must do so… …it’s impractical and inefficient for physicians to step out of the room every time they need to look up something in a journal article or other text resource, all the while getting further and further behind in their schedules”

My thoughts:

I think it’s without a doubt that decisions should be made based on information, and when the healthcare service is spending billions digitalising patient records it’s a nonsensical and dangerous disservice to patients for Doctors to attempt to make their judgements without the support of information.

All the same I think the suggestions from James Wolff and Dr Joel Diamond are examples of the straight line thinking that we have to move on from and I’d be agreement with G. Daniel Martich, MD, CMIO at the University of Pittsburgh Medical Center, that widespread adoption by physicians and their patients is inevitable. Once we fully accept this I think we can see that the presence of information has broken the conventional uninformed Doctor visit model and highlighted the urgent need to move towards a new model such as that outlined in this 2010 Mayo Clinic Proceedings paper and summarised in the following talk upload by Dr John Bachman MD, Prof of Primary Care, Mayo Clinic (and uploaded to Vimeo by PatientsKnowBest CEO Mohammad Al-Ubaydli):

Not only do I think it’s an ill conceived idea to create an advantage in creating a deceptive environment (e.g. where patients are not “able to tell whether their doctor is using a computer in their diagnostic decision or not”) or assuming that patients would be happy for computers to be doing most of the Doctoring (as healthcare treatments are much more dangerous than commercial aviation) but I think it’s absurd that Doctors should feel a need to be “stepping out of the room” as though in denial of the need and importance of fact checking.

I firmly believe that it’s only once we realise and fully accept that all patients are informed and that we are prepared to help them share all their information with their Doctors that a workable solution can be found.

By using interactive tools to let patients share this information with their Doctor before the consultation if they want to, we’re giving the Doctor the best opportunity to add value. Instead of having to start at the beginning with every consultation this tool can enable them to join the patient with an understanding of why they want to meet, what concerns them, how they’re feeling, etc. To give you an idea of the change we’re talking about here, imagine the before and after:

Conventional Doctor meeting a patient who walks in off the street:

“Good morning Mr Doherty, so why have you come to see me today?”

Informed Doctor who has let the patient share their personal health information before the in person meeting:

“Good morning Dave, I’ve had a thorough read through your detailed report and it was incredibly helpful. With the detailed bio data you’ve been logging for the last 24 months you’re going to be amazed at the research I’ve done, uploaded into your electronic health record and printed off a copy for you here. It’s quite obvious that the standard treatment for this condition is XYZ but I’ve found a large patient group that have responded brilliantly to this particular more modern treatment detailed here and I’ve talked to the specialist involved, shared with her your data and apart from these 2 particular considerations that are outlined in detail here we’ve agreed that it’s by far the best course of action we can recommend to you at this stage”

So what do you think the patients opinion of this Doctor is going to be? Is he merely Googling something for you or properly utilising information communication technologies to better serve your needs? Once your Doctor has started moving towards this future model would you really prefer such a high quality interaction to be completely impersonal and computerized?

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6 Responses to Has the computer killed the conventional Doctor visit or provided the biggest opportunity for reform?

  1. James Wolf says:

    My research in this area highlights the irrationality of patients. For the HL article, I reported the findings of my most recent studies, not my beliefs. Further, in my comments about decision support tools being unnoticed by patients, I was suggesting that future tools will be seamlessly embedded into the normal HIT/EHR systems — and less obvious to patients.

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