Doctoring and the Device Paradigm

Before doctors see a patient, they perform a procedure called “chart review.” This involves reviewing the patient’s history, medications, lab or imaging data, and notes from any recent specialist visits or hospital stays. There is variation in how much chart review one prefers to perform before meeting a patient, but in general it is good and necessary to be sufficiently informed and prepared before the visit. But chart review can be a double-edged sword: it can save time and help put the history you obtain and the physical exam you perform into context, but it can also box you in to a false understanding of who the patient is. In the age of ubiquitous electronic health records, which promise an ostensibly more efficient method of chart review but also contain vast amounts of information, chart review can become daunting.

The abstract representation of a patient that is based on electronic health record data alone is what Abraham Verghese has called the “flipped patient” or “iPatient.” Like most of my colleagues, I routinely familiarize myself with the iPatient before going to meet the real patient. Their story is told in numbers, flowsheets, radiology reports, and poorly written, heavily templated clinical notes. Several years ago, when my wife’s grandfather – “Opa” – presented to the ER with shortness of breath while I was on service in the hospital, I learned the value of meeting the real patient first.

I only learned of his arrival because I was notified by my family, and I could not access his medical record. Instead, I went straight to meet him in his emergency department room. On my elevator ride down, I thought about his shortness of breath. I knew that he had had a myocardial infarction earlier in the year, treated with the placement of a coronary stent.

When I walked in the room, he looked almost as pale as the bedsheets. When I shook his hands, I noticed that they were cool. He described feeling lightheaded whenever he stood up at home and was so short of breath that he wasn’t able to walk across his living room – a drastic change in his functional status. All of these signs suggested a common cause – anemia. However, the iPatient’s story suggested at a different suspected cause: new or recurrent heart problems. Or so I learned when the ER doctor stopped by.

According to the ER doctor, Opa’s ECG did not suggest a heart attack this time, and his basic lab tests were not back yet. The ER doctor wanted to admit him overnight due to his history, in order to rule out another myocardial infarction. These “chest pain rule out” admissions are common and routine, so the story made sense from a procedural standpoint. But before I left the room and reassured Opa that I would check in on him when he was in his hospital room, his lab results were back. His hemoglobin had dropped from 12 down to 5, confirming severe anemia.

Since the appropriate lab evaluation had been ordered, my picking up on the signs of anemia did not alter the outcome of the case. Further, a recurrent heart problem was a “can’t miss” diagnosis, and it was rightly at the forefront of the ER doctor’s approach. Yet the correct diagnosis was available through observation. I still think of Opa’s case when I get lost in the weeds of chart review and need to remember that sometimes, the most valuable information is gathered from the patient by using our eyes, ears, and hands.

More recently, I have continued to think about the way in which contemporary technologies shape our approach to doctoring. In a recent article, I borrow Hans Borgmann’s concept of the “device paradigm,” from his 1984 book Technology and the Character of Contemporary Life, to describe the effect that electronic health records (EHRs) have on doctoring. For Borgmann, a technological device is one that makes some good “instantaneous, ubiquitous, safe, and easy,” in a way that is independent of that good’s traditional context. His prototypical example is central heating. In contrast to a hearth, with central heating the heat is delivered safely, easily, and instantly, and the person enjoying the heat is not tied to the context of its source or production, as they would be if they were heating their home with wood. Devices, Borgmann continues, place no demands on one’s “skill, strength, or attention.”

Electronic health records (EHRs) have become widespread and integral to the functioning of both large healthcare systems and small medical practices, such that most doctors cannot complete their basic tasks without using an EHR. EHRs fit Borgmann’s device paradigm, by supplying a patient’s health information instantaneously and easily. The trouble with using the EHR in this way is that the context of that information matters, and that clinicians must be skilled at attending to that context in order to practice good medicine.

There are new concerns about the “deskilling” of physicians as a result of AI, but even before AI entered the clinic and hospital there was a documented decline in physician’s confidence and competence when it comes to physical exam skills. As it becomes easier to gather information from the EHR, the skill and attention involved in gathering information from persons are diminished. It becomes easier, and more “efficient,” to review the chart, perform a cursory physical examination, and order labs, imaging, and medications through the EHR. While many perceive labs and imaging to be more “certain” than physical examination, these too are subject to human interpretation. Further, some diagnoses can only be made by exam, and missing them can lead to serious medical errors.

I do not intend to minimize the importance of reviewing the patient’s chart. Oftentimes, a thorough review provides critical information that guides your clinical approach (in the case I described, the fact that Opa was on blood thinners would increase the likelihood of blood loss as the cause of his anemia). Failing to identify key history on chart review can have devastating consequences, especially in the case of complex medical patients. The error comes when we mistake the iPatient for the flesh-and-blood human being in the exam room or hospital bed.

What I instead hope to illustrate is the tradeoff that occurs when doctors approach the EHR as their primary means of information-gathering and decision-making, and the patient as their secondary source. Sir William Osler, who revitalized and reshaped medicine and medical education in the late 19^th century, famously requested that his epitaph include only the fact that he “taught medical students in the wards.” If he were choosing his epitaph today, he would likely include the qualification that he taught medical students at the bedside, and not just in a team room full of computers. While abstract data is important and indispensable, so is information from the history and physical exam. As Osler taught, “our fellow creatures can not be dealt with as man deals in corn and coal.” Instead, he advocated for an approach based on careful observation, wisdom acquired through experience, and the “education of the heart,” all in the service of the patient.

To counter the device paradigm and our over-reliance on the EHR, we need a renewal of confidence, competence, and wonder when it comes to the richness and depth of information available from a patient’s story and a physical examination. Many have already recognized this. Initiatives such as the Society of Bedside Medicine are working to educate and inspire clinicians to approach bedside evaluation with confidence and competence. As Brian Volck put it at the 2022 FPR conference, we need to return to practicing medicine “as if bodies actually mattered.”

Image Credit: Gustave Courbet, “Village Edge in Winter” (1868) via Städel Museum.