I shift in my seat as I peer through the plexiglass. The only thing visible above the computer monitor is her hair slicked tight to her scalp, parted just left of center. Her darkly penciled eyebrows dance above her thick-rimmed purple glasses, waves above the ocean, as her acrylic nails strike the plastic keys. Clack, clack, clack. Her gum snaps in her mouth. “We switched to a new computer system,” she informs me distractedly. Five minutes tick by. She murmurs softly out loud to herself while she completes each data entry. As she fills in the last box, she finally peers over the monitors to look me in the eye for the first time since I walked in the clinic door. “Remind me of your name?”
In the exam room, the echo is loud. The clack of the keyboard declares itself yet again, a lifeless reverberation against the pale yellow plaster walls. “We switched to a new computer system,” the nurse interjects over the rhythm of the keys. Her gaze never leaves the monitors. Clack, clack, clack. She stands up and leaves without a word.
The physician enters the room, sitting down at the computer. It seems like her entire job is to fill out a form. The glow of the screen reflects against her glasses. Clack clack clickety clack, sing the keys. “New computer system?” I venture. She laughs. “Yes, the joys of modern medicine.”
I left my primary care clinic that day feeling like I hadn’t really seen anyone—like no one had really seen me. I felt like I had been seen by a computer. “I’m going to be different when I’m a doctor,” I told myself. “I’m not going to be so dependent on the screen.”
One and a half years later, I started my clerkships as a medical student. My first rotation was in family medicine. I was at Dr. Deb’s community clinic in Fishtown with no electronic health record—we did all of our SOAP notes by hand. After each patient encounter, I’d stand in the hallway and write up a note on the yellow lined cardstock. By the end of each day, the side of my cramping right hand was smeared in blue ink. I was tired, but I was happy. I’d seen and met so many people, from truck drivers to new mothers to college professors, and they’d offered me the privilege of listening to and learning from their life stories.
In February, I began my internal medicine rotation at Presby. We rounded from 8am to noon every morning, our little team patrolling from patient room to patient room around the hospital. By the end of rounds, I was tired, but again, I was happy. I loved clinical care. All of the conversations we had with patients each morning brought me joy—getting a granny to drink her Ensure, seeing the smile on Mr. G’s face, meeting the parents of Ms. M. This was why I had chosen to pursue medicine.
However, I soon learned that these were known as “walk rounds,” and they were the exception. It turns out that “sit rounds” were much more common, at least during my medicine clerkship. Each intern and medical student sat behind our computers in the workroom, reciting overnight events, vitals, labs, a differential, and a plan for each patient. I found the content of the discussions themselves quite interesting and enjoyed thinking through the medicine with my team. However, I couldn’t help but ask myself each morning during the course of these four hours, “Where are the patients?”
Back in the windowless workroom after noon conference each day, the air hung still. We sat quietly at our computers, the silence only broken by the occasional consult call or question about a patient’s discharge. Clack clack clack, the keyboards declared their rhythm. They formed a symphony, each marching out their own tune, echoing off the plain plaster walls. I peered over my interns’ and senior resident’s shoulders—updating Carelign, messaging the nurses and social workers, ordering medications, signing notes. I spent my afternoons pending orders and writing discharge summaries. Clack clack clack, sang the keys. Yet again, I’d think to myself, “Where are the patients?” Some afternoons, I would step out of the workroom just to go spend time with them. Sitting by their bedsides and getting to know them brought depth to my work—a face behind the name in the top left corner of Epic. Chatting with one of our patients for a few minutes would always remind me what the computers were all for.
There were many things that I expected in medicine: long hours, lots of learning, emotional moments with patients, difficult conversations, and rewarding encounters. All of these, I found—and loved—on my IM clerkship.
One thing I didn’t expect, however, was how little time I would spend with patients. I saw each of my patients for the 5-10 minutes that I pre-rounded on them in the morning, and maybe once again for 5-10 minutes in the afternoon if we weren’t “too busy.” The entire rest of the day was spent on the computer. In an eight-hour day, at most an hour was spent with patients—the rest was spent typing away. Clack, clack, clack, held hostage by the rhythm of the keys.
I’d wager a guess that most medical students didn’t realize they were signing up for so much computer time. I love medicine, but I am saddened by how tied it has become to the electronic health record. As I pursue my PhD in Health Care Management and Economics, I understand the purpose of documentation for the sake of patient safety, and I acknowledge that the EHR is our main vehicle for billing. However, this has become the all-consuming center of our days—responding to messages, charting in the evenings, meticulously documenting each task in Epic. Sadly, when I think back to my IM clerkship, the workroom comes to mind before the patients.
I remember my pediatrician, Dr. Schlundt, whom I saw until I was ten years old. His notes were hand-written in a white binder. I can still see and hear it now, pages turning as he rifled through my chart. I remember his face, his eye contact, his adorably awkward demeanor, his smile. I felt like he knew me. Dr. Schlundt was the kind of doctor I wanted to become—one who sits, who nods, who holds hands, who looks their patients in the eye and promises to do their best by them. This is the kind of doctor I saw in Dr. Deb, too, because there simply were no computers to take time away from patient care.
Whether I become a surgeon or an internist, I will strive to embody these qualities of compassion and accompaniment. Unfortunately, because of what our healthcare system has become, physicians have to work harder to make this a reality, to break the rhythm of the keys. Clack clack clack. The further I progressed in my medicine clerkship, the more comfortable and familiar I became with Epic and the computer. This scared me—I was worried that I would become the doctor I said I never wanted to become, glued to a screen.
As our healthcare system becomes increasingly dependent upon and intertwined with technology, it will be imperative to understand its effects on trainee well-being and their perception of their work. With mounting paperwork and demands from the system, it is no wonder that burnout and unionization rates are as high as they are. Those who once entered medicine as a calling now perceive it more as a job, for better or for worse.
However, I remain hopeful that this is a transition phase, that we will find a way to coexist with the computers, to set our rhythms in harmony. Paradoxically, artificial intelligence may offer this window, automating some of the computer tasks like note-writing and patient messaging so that the clinician can spend more time with patients (and more time at home). Technology is a reality of our current and future healthcare environment, and it isn’t going anywhere anytime soon—“the joys of modern medicine,” as my own PCP had described it. Even if we will never go back to the world of Dr. Deb or Dr. Schlundt, we must find a way to work in tandem with technology rather than against it. I’m hopeful that one day, I’ll no longer be asking myself where the patients are, because I’ll be sitting with them while the computer takes care of itself.
Aidan Crowley is an CDY3 at the Perelman School of Medicine.
