Changes to Doctor-Patient Communication

Doctor-patient communication is a commonly talked about portion of medicine. It is possibly

one of the hardest components for some doctors, and one of the things that is the least teachable.

According to Kee, despite communication skills training in medical school, junior doctors continue to

demonstrate poor patient-doctor communication6. This is an interesting point. This article draws the

conclusion that younger doctors have issue with communication, while doctors experience and further

development through interactions with patients improve their doctor-patient communication. One

article described doctor patient communication as a relational dynamics similar to personal

relationships, but with the additional goal of diagnosing and treating a patients presenting biomedical

and illness concerns.5 There are endless stories told between family members about how you tell the

doctor one thing, but they hear something totally different, or feel like they arent listening to you at all.

Technology has recently come on the scene and has been changing how doctors communicate not only

with patients, but also other care providers, and the nursing support staff. Other care providers is a

fairly broad term, and encompasses not only other doctors, but also nurse practitioners and physician

assistants that see patients as well. I spoke with the head of nursing at Dignity Healthcare in Woodland,

Danielle Caster, and she has seen how technology has come in and changed the field as a whole, and

said that it has completely made it better.3 It is also worth noting that studies were conducted that

correlated computer efficiency with perceived efficacy of EMR4. The introduction of technology has had

an overall positive impact on the doctor patient communication process. However with the new

technology, there also has to be an adjustment in the patient communication practices to ensure the

continuity of patient centeredness.

The introduction of Electronic Medical Records (EMRs) has been very positive from a lot of

viewpoints, the nurses have been able to see the entire chat with a click of a button and see provider

instructions3 where before EMR was introduced, they would have to call for charts. This has
streamlined the flow of care in the eyes of the nurses, and has lessened the amount of additional work

needed to retrieve potentially vital information. EMR systems are thought of by a lot of care providers

as being a very positive influence on the flow of work and overall quality of care. There is a literature

review of the information available in the field which noted that with the computerization of healthcare,

EMRs have an array of benefits. These benefits range from comprehensive documentation of a

patients medical history, easy access to medical data from remote sites, improved communication

among the various providers involved in health care, easy access to medical information and state of the

art resources over the internet, and clinical decision support.1 With all of the potential benefits stated

in the literature and confirmed by Caster, there are some potential disadvantages of EMRs.

Disadvantages of EMR that were reported were that EMRs have altered the process of critical

reasoning, resulting in a possible loss of information, changes in clinical workflow, new types of errors1.

While it is noteworthy to consider the change of workflow, information loss and new errors, this is most

likely due to a transition to a new style of documentation rather than an actual negative impact due to

the technological advancements. It is worth noting that the literature review that found disadvantages

was conducted in 2009, when EMR management systems were first being released. The literature

review continued to consider the influence of computer use on patient-doctor communication (PDC)

during the patient visit. The article noted that communication is one of the most powerful,

encompassing and versatile instruments available to a physician, and it is widely accepted that PDC is

possibly the most significant component of health care visits1. This is an interesting point raised by the

article. It is apparent that doctors on computers do spend a lot of time working on information input

rather than listening to patients. This is evident anytime you go to a doctor that is trying to work with a

computer. Every time I have personally been to a doctor and they are trying to enter information on the

computer it seems they spend more time trying to type on the computer than interacting with their

patient.
 This deviation from the classical patient centeredness focus could be due to a variety of factors.

It may be because they are learning a new system, or that the older generation of doctors are not nearly

as technologically savvy as the newer generation will be. While the initial introduction of EMRs may

have forced computers on doctors who dont use them frequently, younger doctors would most likely

be more comfortable with computers, and willing to adapt. There was a study that found a relationship

between computer experience which was able to predict the way practioners viewed EMR.4 It is worth

considering that while electronic management makes an overall better experience and relay of

information for tech savvy doctors as well as patients, if it impacts PDC for the current generation of

doctors then that needs to be addressed. A lot of doctors now employ scribes, who are responsible for

recording the communication between doctors, entering vitals and managing the information in the

system. The above article as well as other similar literature reviews indicate this may be a reason why

the prevalence of scribes is so high today. Scribes allow doctors to remain focused on the doctor-patient

communication during the visit, mitigating the previously mentioned issue, while allowing the new

technology to improve the care provided to the patient.

The above paragraphs have addressed a potential negative impact on patient centeredness

during the visit. I also wanted to address the doctor-patient communication post visit, since this is

another very important thing to consider. Again, I spoke to Danielle Caster, and she spoke positively of

the doctor-patient communication post visit. She said patients are now able to access an online portal

and access their lab and imaging results, or send notes to their providers. Which in the past had to all be

done by phone.3 This is a very important consideration. Ability to see all of your results online

provides an ease of mind to the patients which was not previously available. The doctor may read

results over the phone, however now they can have a visual printout to look at rather than just words

read over the phone. Also, the ability to send messages directly to the doctor is invaluable. If you have

ever played the telephone game, you can understand why sending a message directly is much better
than having to call, sit on hold, and leave a message for the doctor, hoping they call you back. If you

send a message, you generally get a response within the same day, and your exact message is received

by the doctor. With a message transcribed by a receptionist, and then passed along to the doctor, there

is a higher chance that the doctor doesnt get the entirety of the information left by the patient or

forgets to call the patient back. This aspect of EMR and the introduction of online tools has increased

patients satisfaction with physicians familiarity with them, communication about medical issues and

comprehensiveness of medical decisions1 according to Shachack.

Finally, considering doctor-doctor or hospital-physician communication there can be a clear

difference seen and experienced by personnel within the hospitals from before and after the

information of technology. Looking at a paper published in 2007 that looked at a compilation of studies

from 1970-2005, there was a clear deficit in communication between primary care physicians and

hospitals. The article found that only 3% of primary care physicians reported being involved in

discussions about discharge and 17-20% reported being notified about discharges.2 That means that at

least 80% of doctors had no idea what was happening with their patients and must inform themselves or

hear from their patients on the status of the patients care. This shows a lack of communication, and an

area where the introduction of EMRs could be critical to the improvement of both patient care and

overall patient perception of their care experience. Within hospitals, according to Danielle,

communicating from doctor-doctor or doctor-nurse, they used to have to be paged on beepers or call

the operator to get a hold of other providers. Again, this would slow down the ability of information

relay, and provider availability to patients and other care providers. We now have a device called

Vocera which each nurse and provider carry on their person their entire shift. You simply hit the button

on the device and say the name of the person you are trying to contact, and you can speak through the

device. 3, said Danielle. Again, this shows a drastic improvement in the way that information is passed
within and between hospitals, and out of hospitals to other care providers, allowing for a more patient

centered focus of care.

While there may have been a rough integration, the individuals presently working in the field who

are affected by the new technology on a daily basis have experienced positive impacts. These can be

attributed to the computerization of medical records, the introduction of EMRs, and more efficient ways

of communicating between providers. Originally junior doctors had issues with communication, it

appears that this has shifted back to the more senior doctors. Doctors less comfortable with computers

are too focused on entering information into EMRs. This issue has been addressed by the introduction

of scribes, the continued use of EMRs and streamlining of the system over the past several years. New

devices now allow quick and convenient communication with each other while in the hospital. There

are also communication systems which now exist to allow communication to other providers outside of

the hospital. Doctors have better ways of communicating with patients at home, and have better ways

of managing patient information. Going forward, there should be an increased focus on technology

integration during the patient communication classes in medical school, as well as continued

employment of scribes to ensure patient centeredness. This will allow for all of the benefits of the new

technology, while refocusing on doctor-patient communication.

1. Shachack, A. Reis, S. The impact of electronic medical records on patient-doctor communication

during consultation: a narrative literature review, Evaluation in Clinical Practice, 15.4(2009):641-

649

2. Kripalani, S., LeFevre, F., Phillips, C., Deficits in communication and information transfer

between hospital-based and primary care physicians, JAMA, 297.8(2007):831-841

3. Danielle Caster, head of nursing at Dignity Healthcare in Woodland, CA

4. Likourezos, A., Chalfin, D., Murphy, D., Sommer, B., Darcy, K., Davidson, S., Physician and nurse

satisfaction with an electronic medical record system, Journal of Emergency Medicine,

27.4(2004): 419-424

5. Duggan, A. P., The International Encyclopedia of Interpersonal Communication, Online, Wiley

Online Library, 1 Dec 2015

6. Kee, J. W. Y., Khoo, H. S., Lim, I., Koh, M. Y. H., Communication skills in patient doctor

interaction: learning from patient complaints, online: Health Professions Education, 20 Apr 2017