Computers can't listen--Algorithmic logic meets patient centeredness
Pearce C, Trumble S. Computers can’t listen--Algorithmic logic meets patient centeredness. Aust Fam Physician. 2006 Jun; 35 (6): 439-42
Objective: To explore the rise and fall of doctor-patient relationship in general practice in Australia and study the effect of computers on patient-centered care.
Methods: The authors take the help of various prevailing models to explain the existing doctor-patient relationship and cite studies and surveys from literature to support their arguments.
Discussion: The importance of doctor-patient relationship has been recognized by physicians from Hippocrates to the present day. General practice in particular rediscovered the importance of doctor-patient relationship in the latter part of the last century. Doctor-patient relationship is subject to a paradigm change and has been threatened by different forces at different times:
Before World War II: Biomedical Model:all symptoms are classified into disease based taxonomy and are then dealt with in a linear fashion. This model was dominant before World War II and authors contend that it was not adequate to explain patients and their illness behavior and that medical consultation are not linear.
In early 1950’s: two seminal works gave rise to a new way of thinking. Michael Balint, an English psychiatrist, in his book “The doctor, his patient and the illness” revealed that by far the most frequently used drug in general practice was the doctor himself in a therapeutic relationship. At the same time, Thomas Szaz (another psychiatrist) outlined three models of doctor-patient relationship: active/passive, guidance/cooperative and mutual participation, in increasing order of patient participation.
1969: The term ‘patient centered medicine’ was coined: patient and not the disease should be the doctor’s focus.
1975: Bi-psychosocial Model (George Engels): emphasized the physical and psychosocial background of patients.
Moira Stewart et al defined Patient Centered Clinical Method (PCCM) as: • Exploring both the disease and the illness experience • Understanding the whole person • Finding common ground • Incorporating prevention and health promotion • Enhancing the doctor-patient relationship • Being realistic
Authors cite studies by Bertakis et al (1991) and Little et al (2001), which reveal increased patient satisfaction and enablement with patient-centered care, which may be at risk by introduction of computer-based algorithmic rigidity to the general practice consultation.
Computers and Evidence Based Medicine in General Practice: In 1989 nationwide randomized survey in Australia, 41% of GPs expressed concern that computers would adversely affect the doctor-patient relationship but patients were not bothered by the computer except concerns about privacy and confidentiality and some welcomed their use. Observational study by Als and another study by Pearce et al in 2005, showed that the interaction between the doctor and patients has decreased with introduction of computers. Evidence based medicine helps doctor deliver ‘best care’ to the patients but has proven difficult to deliver due to organizational, professional and social lessons. The computers have facilitated the implementation of evidence based medicine in general practice but has the potential to cut across a more flexible and mutually based doctor-patient relationship. Greenhalgh articulates that it is possible to practice narrative-based medicine in an evidence-based world and that abandoning the narrative-interpretive paradigm in favor of evidence alone creates dissonance.
Conclusion: General practitioner use patient narratives as primary source of information and its accuracy and completeness depends on doctor-patient relationship. Computers and evidence based medicine are useful tools and should be used judiciously in general practice.
Commentary: There is a technological (EBM) and a therapeutic component of health care and both are essential to provide patient-centered quality care and both can facilitate each other. The art of medicine lies in delivering the science of medicine in the social context of doctor-patient relationship. user: skmatta/Shakti Matta