Sue Wootton
Recently I talked at the Dunedin Writers and Readers Festival as part of a panel of health practitioners who write. Called Word Balm, our session set out to explore what language contributes to the practice of medicine. At the end of a wide-ranging conversation, chair Barbara Brookes called for questions from the audience. A woman raised her hand.
This is all very well,” she said, “but how come my GP looks at the computer screen, not at me, throughout the consultation?”
A murmur swept the room. This question clearly resonated with many people present. How come indeed? We know – intuitively as well as from evidence-based science – that good interpersonal skills are the key to good relationships in every sphere of human life, and good relationships are the key to good outcomes. Why then do health practitioners allow technology to interfere with the therapeutic relationship, which is one of the most intimate relationships between humans that any of us will ever experience?
We can try and say it’s a matter of creep, technological creep. And true, in the past ten years technology has infiltrated our personal and professional lives so profoundly that, in the developed world at least, most people have forgotten what it was like to live without a computer or a smart phone. Increasingly it is difficult to be part of society without access to the internet, and it is certainly already impossible to be part of society without your data being loaded into the bureaucracy’s hard drives. Thus we find ourselves on one side or other of the doctor/patient relationship with a computer screen between us. If we’re the patient (and we are all patients, eventually), we may feel that we are speaking to thin air as, all the while, the doctor attends faithfully to the demands of this incomer, this third person in the marriage. Ouch, that’s got to hurt! A little loyalty please!
But in fact it is too late to talk of technology ‘creeping’ into the room. In his illuminating and deeply thoughtful book Thank You for Being Late, New York Times foreign affairs columnist Thomas L. Friedman posits that in 2007 we “entered an age of dizzying accelerations”. Thus, the issue is not banishing the computer from the consultation, but restoring our proper sense of relationship with the computer. This has to mean wresting control of the dialogue back from the machine.
Undoubtedly the computer offers advantages in access to information, and thus, potentially, benefits for treatment. But where we look matters. If the medical gaze is captured by the screen, then the medical mind is locked into a relationship with that screen. The consultation becomes a question and answer session between health professional and computer. Where is the patient? Marginalised, excluded, invisible, unheard.
It seems to be getting harder and harder to hold the vital line against this kind of unhealthy practice. Most health professionals are time-pressured: standard appointment times are too short, and the waiting room is often full. Add to this a strongly enculturated set of pressures to do with beliefs about the benefits of computerisation: that computers increase efficiency, save us time, are fountains of knowledge. The truth is that in interpersonal relationships nothing nourishes efficiency, frees up the flow of time, and improves knowledge like looking at the person with whom you are speaking, and listening to what they are saying. This kind of medical gaze is, odd to say, a patient gaze: gently alert to hesitation, fear, uncertainty, subtext, complexity, ambiguity; to the obvious and subtle ramifications of ill health or disability in this person’s unique, complicated, multi-faceted life.
In an essay called “Doctor, talk to me”, Anatole Broyard wrote of the etiquette of the doctor-patient relationship. He meant the courtesy of attention, the good manners of eye contact and a listening stance. “To most physicians, my illness is a routine incident in their rounds, while for me it’s the crisis of my life. I would feel better if I had a doctor who at least perceived this incongruity.” Diagnosed with prostate cancer, he ponders what he wants in a doctor.
Now that I know I have cancer of the prostate, the lymph nodes, and part of my skeleton, what do I want in a doctor? I want one who is a close reader of illness and a good critic of medicine… I wouldn’t demand a lot of my doctor’s time; I just wish he would brood on my situation for perhaps five minutes, that he would give me his whole mind just once. I would like to think of him as going through my character, as he goes through my flesh, to get at my illness, for each man is ill in his own way.”
We all need to keep insisting on the human-to-human eye contact that nurtures the precious I-thou quality of the therapeutic relationship. But health professionals must bear the primary weight of this responsibility, of upholding the etiquette that protects and nourishes the sacred centre of the work, which is serving others in their suffering.
Sue Wootton is co-editor of Corpus.
So true, Sue, so true.
Veneta Masson (an American nurse) wrote a very good poem about that very thing, called “The Doctor’s Laptop” in a little book called Clinician’s Guide to the Soul published 2008. We need much more “I Contact”.
So true. I recently exclaimed at the joy that my GP actually takes full, thorough notes about things that are important to me (in dealing with my depression and trying to find the right medication, he made note that a previous antidepressant had stopped me from writing and that I was anxious about this happening again) and then actually _reads_ those notes before I walk into my next appointment with him and so always checks as to whether or not I’m writing. (That a doctor doing this should be so surprising and noteworthy is a bit of a commentary on its own.) He uses technology in a great way (and dislikes having to use computers so much), and spends a lot of time turned towards me. Looking at me. Contemplating the options. Discussing those options with me. Turning to his computer to see if there’s some research or a medication that might help. And then coming back to look at me. Of course, he also runs wildly late because he spends time trying to find the best possible option, rather than the option that will sit into a 15 minute slot…..
It’s not only doctors who look at their screens instead of the patient…We see it all the time these days. But a concerning example happened to me some two or three years ago when I ‘acted’ as an elderly (oh I know…I am elderly!!) patient for SDHB ‘nurse assessor’ training purposes. Hour after hour on both days I was there, the training nurses asked questions of their computers (all except one who was a trained former social worker.) I had fun trying to make them look at me. ‘Nurse,’ I’d say, ‘I have a nasty sore on my bottom. Would you look at it?’ (or other distracting things.) I realised that they were all learning the computer programme (and I sure know how complicated that can be) so from time to time I came out of role and made suggestions about addressing me…then recording etc. My memory is that only one took up the advice! I of course relayed my concern to the Course Director and was surprised (if not horrified) at her indifference.This was how ‘assessments for ‘care’ was to be done.
The nurses I met were all caring delightful people but surely the training needed to be ‘client centred’ Sure! Learn the computer but learn how to talk to the patient THEN record!