by Marc Ringel, MD
illustration by Steve Sedam
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. 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, have 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.