During my training in the 1990s, my white coat pockets were stuffed with books. The Internet, in its relative infancy, was not easily accessible in the hospital and contained a tiny fraction of its current knowledge. Back then, information was only at your fingertips when it was committed to memory or in your pocket.
Now, the Internet is at every workstation in the hospital, and all orders are entered electronically. Questions about any clinical situation are answered online in a matter of seconds. As a result, I spend much of my time not with my patients but in front of a computer—entering orders, reviewing labs, writing notes, and reading and sending email.
There is tremendous interest in increasing quality of care, patient satisfaction, and improving communication between doctors, patients, and caregivers.
However, our reliance on technology encourages physicians to spend time at computers that might be better spent with the patient. It seems like we could do a better job of integrating technology into a patient-centric hospital environment.
A few years ago, our hospital installed wireless access to our internal computer network and the Internet. To provide computers to the staff on the wards, the hospital now provides two or three COWs (computers on wheels) to each ward. Unfortunately, their physical design leaves a lot to be desired. They are large and bulky, and they can be hard to move around. The physician must stand with these machines between them and the patient, and even taking a few minutes to find one can feel like a burden during a busy day.
In stark contrast, many patients bring their own laptops into the hospital. They are able to research their condition online, and can be more connected at times than the doctor who is expected to know all the answers.
Because I only have been able to access our hospital network while at a COW, nurses’ station, or my desk, I keep a “to do” list on a piece of paper. My desire to keep a short list and promptly enter orders encourages me to get to a computer as often as possible. While entering my username and password dozens of time each day or waiting in line for a workstation, I can't help but think how nice it would be to spend more time on direct patient care and less time dealing with IT logistics.
Recently, I heard about the value of the iPad in a hospital setting from one of my colleagues. Last week, I set off for my first stint on the wards with an iPad, my stethoscope, a pen, and some business cards. My white coat pockets were empty.
I carried this new lightweight computer like a clipboard. Because of its onscreen keyboard and other characteristics (lightweight, small size, lightning-quick Web browsing), I found that I was naturally sitting alongside each patient as I listened to their concerns. When we determined that a switch of medication or diet was appropriate, I made the change quickly and easily without getting up from my seat—never leaving the patient’s side. Email was available to update the patient’s PCP, social worker, or other care team member.
I spent more time with each patient than I could remember. I did not feel the pressure to hurry out of the room to enter orders as soon as possible. Although I did spend time at a computer during the visit, my patients were able to watch me modify their orders and communicate with their outpatient care team.
Much of the mystery that often surrounds the physician/patient relationship was discarded as we sat side by side. I was able to reconcile medications on the computer with the patient watching and helping make sure that no errors were made. Errors might have been prevented since I no longer had to write down the medications on a piece of paper, carry it down the hall, and enter it on to a computer. It certainly saved me time, enabled the correct list to be entered, and could have provided the patient some confidence that it was done right.
My view of the hospital bed is no longer at the foot, standing up, with weighted pockets. It’s seated, in a chair, at the bedside. I hope to soon master the art of maximizing the benefit of my time with the patient with technology more as a collaborative tool and less as an obstacle.
Melissa L.P. Mattison, MD, SFHM, FACP,
associate director of hospital medicine,
Beth Israel Deaconess Medical Center, Boston