Opinion

VIEWPOINT

Jeffrey Chi, MD Program in Bedside Medicine, Department of Internal Medicine, Stanford University School of Medicine, Stanford, California. Abraham Verghese, MD Program in Bedside Medicine, Department of Internal Medicine, Stanford University School of Medicine, Stanford, California.

Author Reading at jama.com

Corresponding Author: Jeffrey Chi, MD, Division of General Medical Disciplines, Stanford School of Medicine, 300 Pasteur Dr, MC 5209, Stanford, CA 94305 (jeffrey.chi @stanford.edu).

Clinical Education and the Electronic Health Record The Flipped Patient recent clinic notes and other documentation by the emergency department physicians and nurses. Vital signs have been charted, and perhaps the initial examination in the emergency department has already noted important physical findings (or created a bias that there are no physical findings, which makes it likely that physical findings could continue to be missed). Abnormal laboratory values have been highlighted, and a chest radiograph does not need to be viewed because a preliminary report has already been imported. Information on the patient’s past medical history, social history, allergies, and medications is readily available, although not always accurate or complete. Paradoxically, the abundance of drop-down menus on the electronic health record (EHR) and the compulsion to leave no box unchecked often creates a neat construct of a patient that can be a meta-fiction. This construct is often at odds with the real patient, accurate only in the laboratory results and other values but not always accurate in the sense of the patient’s story or the manifestations of illness on the patient’s body. The EHR has great advantages, For a generation for whom texting even if current educational methods can be more intimate than face-to-face have not fully encompassed its presence. Students of this era, for whom conversation, there might be an the touch of a smartphone is as reasassumption that the EHR is the suring as a favorite blanket, find the digital record to be a familiar and weldialogue with the patient, not a come presence, and they spend a sigrepresentation of one. nificant portion of their day attending to it. However, students are just beginlearning have begun to emerge. The long-term ning to realize that technology meant to improve phybenefits of these methods have yet to be proven, but sician efficiency and patient outcomes can also unininitial reactions have been promising. tentionally relegate their role to that of an observer or The same attitudes that have driven changes in at best a passive participant.5 For a generation for the classroom have also unexpectedly led to what whom texting can be more intimate than face-to-face may be referred to as the “flipped patient” model of conversation, there might be an assumption that the learning on the hospital wards. Medical students (and EHR is the dialogue with the patient, not a representaresidents and attendings) are increasingly discovering tion of one. that the first encounter with a newly admitted patient Compared with a computer screen, the living, is electronic3—an encounter with the “iPatient” (the breathing patient (and not a standardized patient) is virtual construct of the patient in the computer), 4 less familiar. A patient cannot be asked to speak faster whom they meet before heading to the emergency or fast forward through an interview; the student candepartment or ward to meet the real patient. In meet- not be looking at 2 other things while talking to the ing the iPatient first, the medical student no longer patient. In short, gathering information from patients needs to ask the time-honored question, “What brings is not an easy task. Students quickly realize that their you to the hospital today?” The presenting problem clinical performance indirectly draws on their skills to and a preliminary diagnosis have already been use the EHR and represent it cogently in discussions entered among a computerized list of medical prob- with their patients, residents, and supervisors. Knowlems. The historical narrative is put together from ing the EHR is in a sense more important than knowing A common sight in the first 2 years of US medical education is that of a professor speaking in a lecture hall that is only half full. An hour later, in the library or elsewhere, students who did not attend the lecture can be seen wearing headsets, watching the recorded lecture at 2× to 4× speed on a desktop, while looking up reference material on their laptop. This trend should not be surprising, because the much-talked-about “millennial” generation has many distinguishing characteristics—but it is their facility with technology and their attitudes toward learning that stand out and that have changed the educational landscape. Many institutions have introduced the “flipped classroom” teaching model in the first 2 years, a method tailored for “millennial” learning.1,2 This new flexible format allows students to learn at their own pace with online videos, followed by interactive, small-group, classroom sessions designed to integrate and apply what was learned. Similarly, other online interactive teaching models that leverage collective

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Opinion Viewpoint

the real patient; mastering the former can often pass for familiarity with the actual patient. Students are also a product of their environment. They often emulate the behaviors of their supervisors and mentors. The forces drawing the student to the computer are precisely the same forces drawing the residents and attending to spend much time there. Night floats and morning handoffs often leave teams with insufficient time before rounds to really know a patient6 but just enough time to know what has been electronically charted. The EHR allows consultants to make triage decisions and curbside recommendations, patient unseen. Attendings are tasked with more computer-based tasks than ever, including computerized problem lists, anticipated discharge dates, and other quality initiatives to refine the data in each patient’s chart. Patients also expect their physicians to have read their EHR in advance. When patients are repeatedly asked the same question, it can undermine their confidence in their care, and often prompts them to ask, “Have you not read my records? It’s all in the computer.” It used to be said that 80% of clinical problems can be diagnosed from the patient history. 7 If the student rarely has the experience of extracting the story from the patient, it must affect diagnostic skills. Phrases such as “Family history—There is no history on file” can populate the chart and unfortunately also may be read aloud at the bedside by trainees. Content can be posted by anyone, and elements of the history could change from chart lore to repeated fact. The synthesis of a patient’s problem is often a collage from other parts of the chart, making it difficult to know whether the student has independently formed an assessment or has just mastered how to extract information from the computer. “Presenting the patient” by the student or the resident can thereARTICLE INFORMATION Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Verghese reported receiving royalties from Scribner and Random House and serving on the speakers bureau of Leigh. Dr Chi reported no disclosures. REFERENCES 1. Gunderman R. Is the lecture dead? The Atlantic. January 29, 2013. http://www.theatlantic.com/health /archive/2013/01/is-the-lecture-dead/272578/. Accessed November 20, 2014.

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fore become a hollow ritual. Accordingly, the format of bedside teaching rounds should not focus on “presenting” the patient8 but rather on the entire team going to meet the new patient. This time at the bedside is a great opportunity to confirm the history, overcome bias, demonstrate elements of the physical examination, and address patient concerns. The “flipped classroom” has been a great innovation for the first 2 years of medical school; the “flipped patient” learning method is quite unintended. There is merit in encouraging students to attempt a history de novo and without bias, by eschewing the EHR and instead meeting the patient directly. For instance, students could say, “I know you may have gone over this with the others, but I have purposely chosen to visit with you directly and hear your story firsthand before reading the records. Would you mind telling me what brought you to the hospital today?” Students are encouraged to then form their own opinion from the history and perform their own examination before looking at what has already been done. This minimizes the temptation to embark on a scavenger hunt within the EHR and then conduct a reverseengineered interview with the patient later on. While it is important that students gain familiarity with the EHR during their training, this new technology must be accompanied by close observation and guidance. Given student preferences for flipped models of information acquisition and their desire to emulate house staff behavior, this will prove to be a great challenge. Millennial students are especially adept at leveraging technology to increase efficiency. Ultimately, however, the nature of medicine is the interaction of a vulnerable human being in distress with a caring empathetic team represented by other humans. It is vital to set EHR guidelines during training to foster skill in getting to know and care for patients.

2. Prober CG, Heath C. Lecture halls without lectures—a proposal for medical education. N Engl J Med. 2012;366(18):1657-1659. 3. Chi J. Behaviors and Attitudes of Medical Student Electronic Health Record Use. Abstract presented at: Association of American Medical Colleges Western 2013 Regional Conference; May 4, 2013; Irvine, CA. Abstract No. 9. 4. Verghese A. Culture shock—patient as icon, icon as patient. N Engl J Med. 2008;359(26):2748-2751. 5. Massey PR, Anderson JH. Resuscitating inpatient clinical clerkships: a medical student perspective. JAMA Intern Med. 2014;174(9):1440-1441.

6. Hampton JR, Harrison MJ, Mitchell JR, Prichard JS, Seymour C. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J. 1975;2(5969):486-489. 7. Dhaliwal G, Hauer KE. The oral patient presentation in the era of night float admissions: credit and critique. JAMA. 2013;310(21):2247-2248. 8. McGee S. Bedside teaching rounds reconsidered [A Piece of My Mind]. JAMA. 2014;311(19):1971-1972.

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Clinical education and the electronic health record: the flipped patient.

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