In 1948, LIFE magazine published a photo essay by Eugene Smith titled "Country Doctor." Each grainy photograph is magnetic. The images capture more than Dr. Ceriani and his patients in a rural Colorado community; they capture the human connection that is at the heart of any healing relationship. I ache for more of that connection in my daily practice.
Whether Dr. Ceriani is checking blood pressure, beaming at a squalling newborn or peering at an eardrum, the connection between him and his patient is at the center of every image. His attention never wavers. Nor is it drawn away to a screen — in fact, none of the images show Dr. Ceriani consulting a medical record of any kind.
What the photos do show is Dr. Ceriani in pinstripes, on a home visit to a bedbound patient with a fever. Later at the office, he reviews an X-ray, takes sutures out of a boy’s hand, and sits at his desk, deep in conversation with a patient. Other moments are not so idyllic: One photograph captures Dr. Ceriani’s face, sweaty and ashen, preparing himself to tell the parents of his young patient that they must take her to Denver to have her eye removed.
Recently, I’ve wondered what a photographer might capture if he followed me. The images would show comparable moments. I, too, remove sutures, evaluate fevers, and counsel patients at my desk. I often pull up X-rays to review with patients, although unlike Dr. Ceriani I do not do so with a cigarette dangling from my lips.
But in truth, most of the photographs would capture me gazing at a computer screen and pushing around a mouse. That is what I spend most of my time doing.
A few months ago, a patient came to see me for a cough: dry, lingering, worse at night. I started to place an order for a chest X-ray while we went on to talk about his arthritis, but after a few mouse clicks and taps on the keyboard, I realized that he’d stopped talking.
“Hey doc,” he said. He waved his hand between my face and the screen and snapped his fingers. “Are you listening?”
I was humiliated. I sat not three feet from him, yet I was so far away that he had to snap at me to bring me back.
This is the central dysfunction of my primary care practice: I am so distracted by the electronic medical record, or EMR, that I can’t pay attention to my patients.
EMRs are an essential tool in medicine. Practicing medicine has grown exponentially more complex since 1948 — even healthy patients have volumes of data that we must follow: allergies, screenings, vaccinations and so on. Pen, paper and the foggy human memory are entirely inadequate.
In addition, our fund of medical knowledge has exploded. While Dr. Ceriani could have expected medical knowledge to double over the 50 years of his career, it now doubles, by one estimate, every 73 days. Physicians must rely on references and guidelines to provide care to patients, and the easiest way to access that vast quantity of information is through a computer screen.
But using an EMR is a complex and time-consuming task. When I next ordered a chest X-ray, I kept count, and it required 22 clicks of the mouse and 54 key strokes.
And entering orders is only a small portion of what I do with the EMR. A recent time-motion capture study showed that for every hour physicians spend seeing patients, we spend two hours using an EMR to review labs and imaging, write letters, and document visits. It is no wonder that our profession is beset with a burnout epidemic. Being present with our patients seems almost an afterthought.
Of course, returning to Dr. Ceriani’s practice environment is not realistic or desirable. He could offer few treatments to his patients, most not very effective. And I do not wish to romanticize a time when racism, sexism and classism so ardently plagued medical practice.
But I cannot look at "Country Doctor" without a searing sense of loss for our profession. In each image I see that ineffable moment of connection in which a caregiver is wholly focused on a patient’s concern. I long to establish that connection with each of my patients, whether we are discussing a new tumor or a fleeting rash. But so often, I am running late, the patient needs orders placed, and the screen pulls me away.
Yes, EMRs are indispensable. But the way we currently use them erodes our relationships with patients. There are efforts to address the problem: scribes to take down notes and orders, sophisticated dictation software, and care teams to help with aspects of a visit such as verifying medications. All of these interventions do help — but they are insufficient.
I know that in order for me to establish that connection with a patient, I need time. Time to listen to my patient and to pay attention to her. Then, I need more time to attend to notes and orders in the EMR, without being rushed into my next visit.
The poet J.D. McClatchy once wrote that “love is the quality of attention that we pay to things.” Indeed, Dr. Ceriani’s love for his patients radiates from every image in "Country Doctor." By that measure, it is easy to understand the despair of so many who have concluded that our health care system is irretrievably broken. We pay more attention to our EMRs than to our patients because we do not have enough time to give the attention that each require.
I am hopeful that we can bring more time for connection back to our clinic rooms. If we are successful, the next time-motion study of physicians will show us completely still, our attention wholly focused on our patient, with our computer in the corner, screen dark, only an afterthought.
Audrey M. Provenzano is a primary care physician at MGH Chelsea Health Center. She frequently writes about health care and is host of "Review of Systems," a podcast on health systems with the Harvard Center for Primary Care. You can follow her on Twitter @audreymdmph.