When Alice S. brought her young son to a private specialist, she was surprised that the doctor
sat across the room throughout most of the appointment, keying information into his computer. Tests were
ordered, drugs were prescribed, and at the end of the appointment, a computer printout was given to her
"that explained everything."
Other patients may not even make it in for a visit. A Texas-based company, for instance, has taken the
"plugged-in" physician out of the exam room altogether by developing a communication tool that
allows patients to provide a medical history in the waiting room or even from home online. A computer
program prompts patients to answer questions based on previous positive responses, shortening the exam
time or eliminating it all together.
Technology, time constraints and financial pressures have altered how doctors and patients across the
nation interact, and how diagnoses are reached. It's no wonder that patients are feeling increasingly
disconnected from their physicians.
Despite such trends, there is a groundswell in medicine today coming from both sides of the examination
table to bring the human dimension back into medicine. "Patient-centered care" is an
emerging topic of interest that recognizes that the interaction between a doctor and patient can be as
important in health and well-being as a physician's technical competence.
Messenger loses the message
Richard Kravitz, UC Davis School of Medicine professor of internal medicine and director of the UC Davis
Center for Health Services Research in Primary Care, says "ignoring the human dimension has real
consequences, both in terms of patient satisfaction and health."
Kravitz studies how doctors and patients communicate in the office and through the media and how those
interactions impact their satisfaction and care.
Patients sometimes complain that they seem to have a different "agenda" than their doctors.
And when patients feel unheard, they may end up not following their doctors' advice. Such was the case
with Alice, whose doctor, she felt, paid more attention to his computer than to her. Excluded from a meaningful
discussion, Alice decided on her own that medications weren't needed for her son and chose not to fill
the prescription he gave her.
Kravitz emphasizes that patient-centered care involves more than just the doctor spending more time
looking at and listening to patients. It also requires that patients and doctors work together toward
health goals. When patients and doctors share the same perception of a problem, compliance with a treatment
regime is more likely.
Ironically, research indicates that while doctors with a more patient-centered style do spend more time
with patients, overall costs actually decrease as a result. Peter Franks, UC Davis professor of family
and community medicine, has paid particular attention in his research to costs and health outcomes resulting
from different physician styles. "A doctor can either reach a diagnosis by spending more time with
the patient or by ordering more tests. Doctors who aren't as patient-centered need to order more tests
and refer their patients to specialists more often," says Franks. "That is what really drives
up health-care costs."
Curriculum focusing on patients
A patient-centered style can be successfully taught to students and physicians. Michael Wilkes, School
of Medicine vice dean of education, has created the Doctoring Program at UC Davis to help develop students'
communication skills and expose them to a wide range of patient encounters. Interactions are observed
and students receive feedback from their professors, other students, and most importantly, the patients
themselves. The popular program is incorporated into the first three years of the UC Davis medical education
Faith Fitzgerald, UC Davis assistant dean of medical humanities and bioethics, agrees that spending more
time with patients is especially important for students. "Some 35 years out of medical school, what
I remember from my student years is not lab tests, X-rays or contents of lectures," she says. "What
I do remember are interactions with patients and their families."
Tech vs. touch
Fitzgerald expresses concern about efficiency-oriented devices that take time away from face-to-face
interactions with patients, such as the computer program that allows doctors to screen patients online
to determine whether they need to be seen. "I begin my physical exam by observing the patient as
he or she is telling the story," she says. "One can get a completely different impression that
way than by reading the history on a computer screen."
But she also stresses that this does not mean that the human touch is all that is needed in patient-doctor
interactions. Technology has a role, but not necessarily the primary role.
"We need to understand the power inherent in both doctors and technology," says Fitzgerald,
"But in fact, we tend to have less confidence in human ability."
She decries the fact that many doctors feel as if lawyers are looking over their shoulders, making sure
they've ordered diagnostic tests to cover every possible eventuality. While tests are important, she asserts,
so is human judgment, but this quality tends to be undervalued in a lawsuit. Human skill, she emphasizes,
should not be held to a lower standard than technology.
Elevating human judgment
"We must require that what the doctor brings to the table is as accurate and fully functional as
what we require from diagnostic tests," she says. "When the interaction of the physician and
the patient is deemed less important than the contribution from tests or 'labor-saving' computer programs,
this is a real problem. And that holds true for all aspects of diagnosis and patient care."