Would a Scribe Repair or Destroy the Doctor-Patient Bond?

I am Art Caplan, at the Division of Medical Ethics at the New York University Langone Medical Center in New York City.

If we want to make electronic medical records work, do we have to introduce a third party, a scribe, to arbitrate patients' complaints about what the electronic medical record is doing to their relationship with their doctor?

If you speak with patients these days, they will say, "I went in and my doctor had his or her head stuck in a computer the whole time," particularly on a primary care visit. "I couldn't get my doctor to look at me." "I couldn't get my doctor to pay attention to me." "I drone on about my vital signs, my problems, my complaints, or my health status, and the doctor is bent over this data-entry port, looking at a computer, or sometimes staring into a hand-held device, not paying any attention to me."

Certainly, a crucial part of the ethics of doctor-patient relationships is to show respect to the patient. In our culture and in many cultures around the world, one way to show disrespect is to not look the person in the eye -- to not address them directly but to look away and be more fascinated, if you will, with your machine than you are with your patient.

In defense of doctors, they are told that these electronic medical records are much more accurate; they can help guide good history-taking; and they will remind you and cue you when you have missed something, everything from vaccination records to all sorts of questions about sex life and so on that you might not get into. These items are all on the form, and following it certainly helps improve the efficiency of the relationship.

So doctors might say, "Yes, I would like to spend more time talking, informally chatting, and looking at the patient, but I have to do what is best in terms of being efficient and accurate, and that means interacting with my machines as much as interacting with the patient."

Will a Third Party Improve the Relationship or Ruin It?

Enter the scribe. In some practices, people have started to ask, "Why don't we have someone to do the data entry? Why don't we bring someone in who can enter all this information while I am talking with the patient, someone who can sit in front of the machine and enter the information the patient is giving back? In that way, we can capture the best of the electronic medical record and preserve that intimacy and trust in the doctor-patient relationship."

My own view? You have got to be kidding me. The whole point of moving to the electronic medical record was to be efficient. Adding a third party introduces opportunities for error. That scribe will not be able to pick up a mistake while punching in information. The scribe may not realize, the way the doctor would, when the patient has said something inconsistent. Not to say that the doctor cannot monitor what is being said, but data entry by a third party is simply another way to introduce more mistakes and errors.

I fully appreciate the need to spend time talking with the patient face to face, and I do think patients are right to say, "I don't want to talk to the back of someone's head; I want to talk to my doctor." But the answer is not to add a third party. It is to fight hard to make sure that we put a little more time into the doctor-patient relationship, and add a little more reimbursement into the doctor-patient relationship -- use the machines to be efficient, but also compensate monetarily for what people say they want: face-to-face contact with the doctor.

A third party is a Band-Aid on a serious problem. We do not have enough time in medicine to pay attention and listen carefully when we are face to face with our patients. I believe we ought to fix that, rather than introducing another person, along with a new machine, into the doctor-patient relationship.

I am Art Caplan, at the Division of Medical Ethics at the NYU Langone Medical Center. Thanks very much for watching.

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