San Francisco, CA (Spring 2017)
I am six months into my first year of residency as a doctor. And my experience so far has been sorrowfully screen-dominated. If aliens were to come down and observe a day in the life, I am afraid they’d assume the computer is the patient and the patient’s room the place I dictate the day’s plan. I am turning into a hunched and pale C-shape staring into a computer screen, a pager screen, a two-inch, blinking fax machine screen, fulfilling the clerical burden of patient care. Feature me on Sesame Street, strolling down the lane with Big Bird, here is medicine’s technology, brought to you by the letter C, the same shape your kyphotic spine will form as you click your way through the wards.
This technological disorder is not unique to this hospital, or any other. Spending hours on typing, faxing, and paging has somehow become the status quo for hospitals across the nation. I recently watched again the first episode of Scrubs, where a young Zach Braff arrives on his first day of residency, is promptly handed a pager, and told gruffly it will now dictate his existence. That episode ran in 2001. What that sitcom does not show—because it would be excruciatingly tedious—are the hours wasted waiting for pages, typing event notes, and ordering e-referrals.
A large part of my day is spent wrangling the electronic health record, or rather the records. There is one computer system for the emergency room, one for the rest of the hospital, another for the outpatient clinic system. Each stores information in exasperatingly dissimilar layouts. There is a different system for obstetrics/gynecology altogether, hermetically sealed with a teal background and rows of clickable pink and purple boxes. Each record system is like an Easter Island head—unwieldy, big, utterly improbable, existing in complete isolation from everything around it, a glimpse of a mysterious time and culture bygone when, for example, it was an innovation to hit “page down” to access information just below the screen’s edge. Amazingly the intensive care unit, the technological bedrock of preserving human life against all odds, uses exclusively paper charting.
If you need a patient’s medical records from an outside hospital, you Google that hospital’s medical record office, call, ask for their fax line, send over a signed health release form, and then wait and pray for the records to arrive at your floor’s fax machine. If you need to call another doctor (say, to have them translate a semi-legible hand-written note) you page them and then wait for a call back on your yellow, brick-like “banana” phone, attached by plastic holsters clipped to our waistbands. Or you can text page by going to a website entering the pager number, and typing a short message. The superstition cultivated by waiting (im)patiently for pages to be returned, leads to certain wisdoms passed down by senior residents: Always text page! Never text page too long a message! If you don’t get response in 10 minutes, page again!
All told, these processes can be mind-numbingly time-intensive and take one away from being both physically and mentally present for patients and their care.
By my best estimate I spend two minutes alone with each patient in the morning, and then two minutes again with the attending physician present as we discuss the plan of the day. If no emergencies occur, I spend some five to ten minutes with each patient in the afternoon, which equals, optimally and lamentably, fourteen face-to-face minutes with each patient per day. If I have five patients, that amounts to seventy minutes of face to face patient care. If you subtract the four hours of formal discussion, rounding, and lecture during an average eleven-hour day on the wards, I spend six remaining hours cemented to a screen, clicking, paging, and faxing.
My family and friends have often asked how it is we spend so little time with our non-virtual, flesh and blood patients. They wonder ‘why do you use pagers when smartphones exist,’ and ‘are the fax machine execs in cahoots with hospital management?’ I don’t have the answers to these questions but know they are complex problems that have to do with costs, medicolegal documentation requirements, fear of litigation, and systems-based motivations I do not fully understand. Certainly technology upgrades are expensive and complex, and I know there is ongoing work and thought on ways to improve work flow. I cannot help but feel that we have reached a technological impasse, where screens hinder our interactions with patients, rather than helping to log and organize them. Something has got to give, and so far that it has been face to face time.
What I do know is that doctors wish they had more time to talk to patients. It is a consistent complaint from patients that they never get to speak to their doctors, who are rushed, aren’t listening, or typing during the encounter glued to their computer screen. And somewhere piled up between them, are pages and pages of medical documents.
To my fortune, with pager and banana phone holstered to my hip, I am surrounded by remarkable patients, humbled by the medical knowledge and kindheartedness of my colleagues. For now I hope to increase my clicking and paging efficiency. Every minute saved is a minute gained talking to a patient. Fourteen minutes can become fifteen. By next year, I hope it may be twenty.
KATIE TAYLOR, MD, MFA, is a first year resident practicing in San Francisco, CA. She received an MFA in oil painting in Baltimore, and her MD from Mt. Sinai School of Medicine. She currently paints and practices medicine in San Francisco.