Are We Turning Our Backs on Our Patients? Training Psychiatrists in the Era of the Electronic Health Record

Over the past three decades, psychiatry’s focus has shifted away from the couch and toward the computer. Gone are the days when psychiatrists took notes in longhand—or listened without taking any notes at all. Whatever their theoretical orientation, today’s psychiatrists are faced with the reality of the electronic health record, a key provision of the Health Information Technology for Economic and Clinical Health Act of 2009, which mandated that all health care providers billing Medicare adopt and demonstrate “meaningful use” of electronic health records by 2014. Those who work in hospital settings—including psychiatric residents and their on-site supervisors—must find a way to effectively incorporate electronic health records into the practice of psychiatry.

Electronic charting may interfere with the quality of the doctor-patient relationship and, ironically, diminish the accuracy and meaningfulness of medical records.

Electronic health records were meant to facilitate comprehensive evaluations and treatment planning, but the presence of a computer in the consultation room may have the opposite effect. The traditional office arrangement of comfortable chairs and couches naturally lends itself to making eye contact, observing the patient’s appearance and body language, and noticing subtleties in the patient’s affect. A computer divides the psychiatrist’s attention, drawing focus away from the patient. For a new psychiatrist, the computer template may serve as an anchor—a way to feel in control of the interview, a way not to miss important questions—but it also creates a barrier against the patient’s pain and suffering. There is a difference between writing down the patient’s words and hearing the patient’s words. Rather than being forced to see a patient in pain and grappling with overwhelming affect, the resident can look at the computer screen, check the appropriate boxes, and believe that she has done her job. But asking questions using a computer template creates an atmosphere in which the patient may not feel comfortable expressing her more shameful thoughts and feelings, knowing that they are being immediately typed into the record. Even when the patient expresses emotion or achieves insight, typing may limit the psychiatrist’s ability to empathize, understand, and connect.

We are faced with a clinical and educational challenge. Documentation takes time, and not writing notes until after an encounter adds minutes or even hours at the end of the day. Note-taking during clinical encounters has always been a difficult skill to learn. Even for millennials, for whom constant attention to a screen is a normal part of life, electronic charting increases the difficulty of note-taking, particularly in offices where the placement of the computer screen demands that the clinician look away from the patient. How and when the psychiatrist pauses to take a note, whether on paper or on a computer, requires careful thought and training.

Turning our backs on our patients is never acceptable. Our job is to listen, to observe, and to notice things that others might not. Creating a safe, welcoming space in which patients can express their most private thoughts and feelings enables us to capture the important details that form the basis of a comprehensive and meaningful assessment. In the words of William Osler, “Listen to your patient, he is telling you the diagnosis.”