Back to the Bedside

When I survey our academic emergency physicians each year about what they most enjoy about their jobs, the number one answer is always “clinical care” or “taking care of ED patients.” It doesn’t matter whether they’re administrators, educators, researchers or primary clinician-educators. They were drawn to emergency medicine by the broad and deep challenges that roll or walk through our doors. Caring for ill and injured patients efficiently and compassionately requires establishing trust with patients and families. Developing a diagnosis and treatment plan begins with tending to the patient’s story and the findings on physical exam. They really love bedside medicine, but find themselves pulled away from time with their patients.

At the risk of sounding curmudgeonly, I think that many medical “advances” threaten the basic bedside connection that is so essential to being a good emergency physician. Were I to ask my colleagues in the ED, “How many of you think the EHR has made you a better doctor?” I suspect the silence would be deafening. The demands of the electronic health record (EHR) mean that emergency physicians spend much more time palpating a keyboard than an abdomen or injured extremity. The words that we might have been sharing with patients are now often dictated into a microphone or worse, become lost in a train of expletives directed at an illogical, unruly EHR.

The gadgets of medicine have been proliferating, producing monitors that feed us every imaginable type of potentially useful information, providing a sense of security as we remain away from the bedside. New devices are great — until they malfunction, mislead, or are ignored in the hum of alarm fatigue. Fortunately, we are not in a NASA control room, monitoring a distant space flight — we can actually go back to the bedside to have a direct look at an “alarming” patient. But even going back to the bedside is getting more difficult, with newer ED designs working against direct contact and assessment of patients.

Without presenting an extensive review of the literature, here are some basic truths about our current state of clinical care. First, most physicians are frustrated about aspects of digital health and the EHR. Second, many patients, particularly in busy academic EDs,  are unhappy about poor communication with providers, the information that is the provided, and the length of their waits and stays. On the trainee side, medical students and residents note that they may go months without an attending physician directly observing their interactions with a patient. Frustration abounds. So, what do we do about it?

Some of the recent changes we have made in our EDs seem to be enhancing our ability to get back to the bedside and connect better with our patients. As we introduced a new EHR system, we expanded our homegrown scribe program, most of whom are “gap year” pre-professional students. Our scribes are well-trained to generate the medical record so that physicians can direct their attention to patients instead of a computer. This was a key factor in having a successful ED roll out of the new EHR. Our emergency physicians are effusive in their evaluation of how the scribe program has helped them be practicing physicians instead of accomplished typists. Patients also seem to like the verbalization of the physician to a scribe while the history and exam are obtained.

In clinical teaching, we have initiated more bedside teaching by having resident and medical student presentations to attending physicians occur at the bedside. The benefits of this in terms of communication exchange, patient satisfaction, and ensuring patient safety have been more than we imagined. Some thought it might make us less efficient, but the opposite seems to be happening. A number of attending physicians are moving most presentations to the bedside, but our goal is to have this occur at least once per shift for each trainee. We have also formalized this in the residency with standardized direct observational teaching sessions provided to residents by a faculty member who is not on duty in the ED.

In the research realm too much translational research is lost in translation and never makes it to the bedside. We are trying to change this by implementing protocols and techniques from our research that are shown to be valuable in ED care. Our research faculty have the goal of bringing their research findings to ultimate completion by making a difference at the individual patient level.

While I like to think that our emergency department embraces technology, we also have a responsibility to ensure that the technological advances which we implement actually improve clinical care and patient outcomes. For instance, IBM has created a supercomputer named “Watson” that is currently being touted as the world’s greatest diagnostician. But I wonder how Watson will be able to pick up, for example, a subtle domestic violence situation. Will the computer sense the hesitance in a woman’s voice, or identify suspicious bruising, or see a lurking husband around the corner? And even if it could, will it provide some comforting words, or discuss a plan with the patient? I think a well-trained, compassionate emergency physician at the bedside  will still outdo a computer for a while longer.

So, back to the bedside! A rallying cry — a plea — to not dismiss, diminish, or forget what is still the most fundamental part of medicine.

 

Brian Zink (@Zink_Brian) is Professor and Chair of Emergency Medicine at the Alpert Medical School of Brown University. He is an essayist and a poet, and he wrote Anyone, Anything, Anytime — A History of Emergency Medicine, the definitive work on emergency medicine in the United States.

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