APA GEORGE ARMSTRONG LECTURE
Pediatrics and the Lure of Technology Ellen F. Crain, MD, PhD From the Departments of Pediatrics and Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY The author declares that she has no conflict of interest. Address correspondence to Ellen F. Crain, MD, PhD, Department of Pediatrics, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Pkwy S, J1W20, Bronx, NY 10461 (e-mail: [email protected]). Received for publication September 19, 2013; accepted September 19, 2013.
ACADEMIC PEDIATRICS 2014;14:4–7
AMERICA HAS FALLEN in love with technology. Even young children are frequent users of technological devices. Schools, which are rated in part by their computer/student ratios, continually seek additional equipment. Several surveys have found that at least two-thirds of teens have a smartphone and spend time in class networking, shopping, or answering e-mails on their phones or laptops. In fact, a Pew Research Center survey in 2011 found that 18- to 24year-olds in the United States send or receive, on average, 109 text messages a day.1 In 2012, Pew Research reported that 83% of 18- to 29-year-olds used a social networking site, and 67% had a social networking site on their mobile phone.2 Despite technology’s widespread appeal, there are downsides. Teens and young adults often lament that they are addicted to social media.3 MIT professor Sherry Turkle worries that social media sites encourage rapid responses rather than thoughtful, deliberate dialogue. She believes that new technologies sabotage real communication.4 Pediatrics is not immune from technology’s appeal. Vast amounts of pediatric literature, drug information, and treatment options are available on the trainee’s smartphone. However, technology also can be distracting. Here is a disturbing example. On a busy medical ward in a New York hospital, a resident sat down at the computer to D/C a patient’s heparin before surgery. At that moment, her cellphone buzzed with a text inviting her to a party. She responded to the text and became distracted and never D/C’d the medication. The patient went to surgery and nearly bled out (Rachel Katz, personal communication, March 12, 2012). Technology is causing another kind of distraction, which is more subtle and pervasive. As we become more immersed in technology, we are losing sight of the value of one of the basic approaches to learning about our patients.
LEARNING ABOUT PATIENTS At the risk of oversimplification, there are 2 methods of learning about patients. The first is the traditional scientific approach, which is objective, rational, and impersonal. It primarily consists of data gathering.5 Medical education has always put a premium on the traditional scientific
approach; medicine is taught by disease and diagnosis, and we are tested and retested on our knowledge of the biochemical, physiological, and clinical characteristics of diseases. When medical students and residents present cases, they are expected to gather enough facts to put their patient in a diagnostic category. The second method of learning is the interpersonal approach.6 This is the approach that is sometimes identified with the old country doctor or the pediatric giants of the recent past. The physician tries to establish a respectful bond with the patient and his or her family and encourages the family to be part of the diagnostic detective work. During the interaction, the physician tries to make sure he or she understands the family’s main concern, which might not be formally stated at the start of the visit. The interpersonal approach typically is more prominent during the initial phase of the evaluation, but the physician can move back and forth between the 2 methods of learning.7 Although the interpersonal approach has generally taken a back seat in medical education, the increasing appeal of technology puts it at even greater risk. The trainee’s smartphone or computer provides access to management algorithms, case reports, and reference material. As a result, technology moves the center of the trainee’s focus to technological inputs, and we risk losing sight of the interpersonal approach altogether. Miller and Schmidt8 worried that medicine has become too disease oriented and technology driven and is neglecting the interpersonal dimensions of patient care. Serwint9 expanded on that notion, describing how technology, electronic communication, computerized order entry, and work-hour reductions have reduced the time spent with patients in real communication. I had the privilege of training under Dr Lewis Fraad, one of the founders of the APA and a master of the interpersonal approach. He could get crying children to stop crying and even smile as if by magic. This is what one experienced senior physician who knew him had to say: If you saw him in an interaction with a patient, he made that bonding right away and then he went on to find out what was wrong. Before he started to even try to figure out what was wrong with the patient, he would bond,
ACADEMIC PEDIATRICS 4 Copyright ª 2014 Published by Elsevier Inc. on behalf of Academic Pediatric Association
Volume 14, Number 1 January–February 2014
ACADEMIC PEDIATRICS
then he would continue to do that in the context of looking at what was wrong with the child. But the bonding, the initial contact, that glue or whatever it was, made the rest of the interaction happen more easily and more fruitfully. (Interview with Andrew P. Mezey, MD, by William Crain, PhD, December 12, 1990). Another senior clinician shared something his daughter said about Dr Fraad, whom she saw as a patient only once about 15 years before. “He was the only doctor,” she said, “who was able to talk with her, not to her or through her but with her and treat her as an individual human being” (interview with Bertrand Bell, MD, by William Crain, PhD, December 13, 1990). We can gain some insight into the benefits of interpersonal learning from the work of the humanistic psychologist Abraham Maslow. He noted that people generally do not reveal themselves or their feelings when they feel insecure in another’s presence.7 Experienced pediatricians have learned that children, and even parents, may be anxious in the exam room as long as the physician remains impersonal.
WHY THE INTERPERSONAL APPROACH IS IMPORTANT You might ask whether this interpersonal approach is really vital. Isn’t the main goal to get the information needed to make the right diagnosis and formulate a treatment plan? There are 4 reasons why the interpersonal approach does matter. REASON 1: THE INTERPERSONAL APPROACH HELPS US FORM AN OVERALL IMPRESSION OF THE CHILD’S HEALTH One of the first tasks of diagnosis is often the formation of a general impression of the child’s health. It is a sensory impression based on the child’s appearance. Although this impression often strikes medical educators as too intuitive and unscientific, it is often the starting point in many medical algorithms. In a pioneering study by Roberts and Borzy, a general impression was found to be highly predictive of illness—more than any objective test that could be obtained during the visit.10 The same finding has emerged repeatedly, including in studies by McCarthy et al,11 Berkowitz et al,12 and Crain and Shelov.13 This clinical impression usually helps the physician decide whether additional tests—or in some cases hospitalization—is needed. In 1987, William Crain and I tried to gain information on how this clinical impression is formed. We tape-recorded senior pediatric attendings, residents, and interns evaluating infants with fever.14 Nearly all tried to form a clinical impression of the infants’ overall health. However, what surprised us was the striking difference in their approaches to the infants. The advanced attendings formed their clinical impressions by talking and playing with the infants. One of the senior pediatricians we taped was Dr Fraad. First, he introduced himself to the mother and asked her to tell him briefly what was wrong with her baby. He
PEDIATRICS AND THE LURE OF TECHNOLOGY
5
acknowledged how hard it must have been for her to take care of a sick infant. In this way, he built rapport with the mother who would become his ally in figuring out what was wrong and what had to be done. Then he talked to the infant: “What’s the matter, baby, what’s the matter?” He repeated these and similar phrases as if the infant were an older child who could talk back. It seemed that he believed that an interaction with the child was vital. Another senior pediatrician, whom we called Physician 1 in our study, said, “Hello, cute baby, how are you? You are smiling at me and you’re looking me right in the eyes, so I’m not too worried about you, because you’re smiling so nicely..” This physician was forming a clinical impression through interpersonal interaction. In contrast, the interns and residents typically tried to form an impression from a detached, objective viewpoint. They checked off features of the babies’ appearance and behavior. For example, an intern, whom we called Physician 2, took a history from the mother and then said, I have observed that the child has been quiet the entire interview, which indicates that he may have been sick for several days. But he is alert and does respond to outside stimuli so his level of alertness is suggestive too. I notice he has nice large tears, which is indicative of a well-hydrated state. This small sample study, then, suggests that experienced physicians are more likely than trainees to form a clinical impression through warm, interpersonal interactions. McCarthy also found that experienced attendings were much more likely to form clinical impressions based on interaction with the patient and that these interaction-based impressions were the best predictors of serious illness.15 In a second study, we found support for the possibility that as medical students and physicians gain experience they increasingly come to appreciate the intuitive, interpersonal approach. We asked a wide range of respondents, including premedical students, first- and third-year medical students, pediatric interns, and senior residents to read the responses of Physicians 1 and 2 and to guess the physicians’ levels of experience. They were also asked to give the reasons for their guesses. The Figure summarizes the data as the percentages of each group of respondents who rated Physician 1 or Physician 2 as more advanced. The less experienced respondents—the premedical and the medical students— generally rated the interpersonal Physician 1 lower than the detached Physician 2. A majority in each of these groups guessed that Physician 1 was a mere beginner, explaining that Physician 1, lacking scientific knowledge, was relying on “physician appearances” and “vague impressions.” They thought Physician 1 was too personal, “not putting enough distance between himself and the patient.” Physician 2, they wrote, was more “professional” and “objective.” As one respondent wrote, “He uses detached, intellectual terms, which is the goal of medical training.” At the opposite extreme were the senior pediatric residents, who usually guessed that Physician 1 was an experienced attending physician forming an intuitive, sensory
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Figure. Bar graph showing results of respondents who rated Physician 1 or Physician 2 as the more advanced doctor. The percentages for each group do not always total 100 because a small number of respondents (
Pediatrics and the Lure of Technology Ellen F. Crain, MD, PhD From the Departments of Pediatrics and Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY The author declares that she has no conflict of interest. Address correspondence to Ellen F. Crain, MD, PhD, Department of Pediatrics, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Pkwy S, J1W20, Bronx, NY 10461 (e-mail: [email protected]). Received for publication September 19, 2013; accepted September 19, 2013.
ACADEMIC PEDIATRICS 2014;14:4–7
AMERICA HAS FALLEN in love with technology. Even young children are frequent users of technological devices. Schools, which are rated in part by their computer/student ratios, continually seek additional equipment. Several surveys have found that at least two-thirds of teens have a smartphone and spend time in class networking, shopping, or answering e-mails on their phones or laptops. In fact, a Pew Research Center survey in 2011 found that 18- to 24year-olds in the United States send or receive, on average, 109 text messages a day.1 In 2012, Pew Research reported that 83% of 18- to 29-year-olds used a social networking site, and 67% had a social networking site on their mobile phone.2 Despite technology’s widespread appeal, there are downsides. Teens and young adults often lament that they are addicted to social media.3 MIT professor Sherry Turkle worries that social media sites encourage rapid responses rather than thoughtful, deliberate dialogue. She believes that new technologies sabotage real communication.4 Pediatrics is not immune from technology’s appeal. Vast amounts of pediatric literature, drug information, and treatment options are available on the trainee’s smartphone. However, technology also can be distracting. Here is a disturbing example. On a busy medical ward in a New York hospital, a resident sat down at the computer to D/C a patient’s heparin before surgery. At that moment, her cellphone buzzed with a text inviting her to a party. She responded to the text and became distracted and never D/C’d the medication. The patient went to surgery and nearly bled out (Rachel Katz, personal communication, March 12, 2012). Technology is causing another kind of distraction, which is more subtle and pervasive. As we become more immersed in technology, we are losing sight of the value of one of the basic approaches to learning about our patients.
LEARNING ABOUT PATIENTS At the risk of oversimplification, there are 2 methods of learning about patients. The first is the traditional scientific approach, which is objective, rational, and impersonal. It primarily consists of data gathering.5 Medical education has always put a premium on the traditional scientific
approach; medicine is taught by disease and diagnosis, and we are tested and retested on our knowledge of the biochemical, physiological, and clinical characteristics of diseases. When medical students and residents present cases, they are expected to gather enough facts to put their patient in a diagnostic category. The second method of learning is the interpersonal approach.6 This is the approach that is sometimes identified with the old country doctor or the pediatric giants of the recent past. The physician tries to establish a respectful bond with the patient and his or her family and encourages the family to be part of the diagnostic detective work. During the interaction, the physician tries to make sure he or she understands the family’s main concern, which might not be formally stated at the start of the visit. The interpersonal approach typically is more prominent during the initial phase of the evaluation, but the physician can move back and forth between the 2 methods of learning.7 Although the interpersonal approach has generally taken a back seat in medical education, the increasing appeal of technology puts it at even greater risk. The trainee’s smartphone or computer provides access to management algorithms, case reports, and reference material. As a result, technology moves the center of the trainee’s focus to technological inputs, and we risk losing sight of the interpersonal approach altogether. Miller and Schmidt8 worried that medicine has become too disease oriented and technology driven and is neglecting the interpersonal dimensions of patient care. Serwint9 expanded on that notion, describing how technology, electronic communication, computerized order entry, and work-hour reductions have reduced the time spent with patients in real communication. I had the privilege of training under Dr Lewis Fraad, one of the founders of the APA and a master of the interpersonal approach. He could get crying children to stop crying and even smile as if by magic. This is what one experienced senior physician who knew him had to say: If you saw him in an interaction with a patient, he made that bonding right away and then he went on to find out what was wrong. Before he started to even try to figure out what was wrong with the patient, he would bond,
ACADEMIC PEDIATRICS 4 Copyright ª 2014 Published by Elsevier Inc. on behalf of Academic Pediatric Association
Volume 14, Number 1 January–February 2014
ACADEMIC PEDIATRICS
then he would continue to do that in the context of looking at what was wrong with the child. But the bonding, the initial contact, that glue or whatever it was, made the rest of the interaction happen more easily and more fruitfully. (Interview with Andrew P. Mezey, MD, by William Crain, PhD, December 12, 1990). Another senior clinician shared something his daughter said about Dr Fraad, whom she saw as a patient only once about 15 years before. “He was the only doctor,” she said, “who was able to talk with her, not to her or through her but with her and treat her as an individual human being” (interview with Bertrand Bell, MD, by William Crain, PhD, December 13, 1990). We can gain some insight into the benefits of interpersonal learning from the work of the humanistic psychologist Abraham Maslow. He noted that people generally do not reveal themselves or their feelings when they feel insecure in another’s presence.7 Experienced pediatricians have learned that children, and even parents, may be anxious in the exam room as long as the physician remains impersonal.
WHY THE INTERPERSONAL APPROACH IS IMPORTANT You might ask whether this interpersonal approach is really vital. Isn’t the main goal to get the information needed to make the right diagnosis and formulate a treatment plan? There are 4 reasons why the interpersonal approach does matter. REASON 1: THE INTERPERSONAL APPROACH HELPS US FORM AN OVERALL IMPRESSION OF THE CHILD’S HEALTH One of the first tasks of diagnosis is often the formation of a general impression of the child’s health. It is a sensory impression based on the child’s appearance. Although this impression often strikes medical educators as too intuitive and unscientific, it is often the starting point in many medical algorithms. In a pioneering study by Roberts and Borzy, a general impression was found to be highly predictive of illness—more than any objective test that could be obtained during the visit.10 The same finding has emerged repeatedly, including in studies by McCarthy et al,11 Berkowitz et al,12 and Crain and Shelov.13 This clinical impression usually helps the physician decide whether additional tests—or in some cases hospitalization—is needed. In 1987, William Crain and I tried to gain information on how this clinical impression is formed. We tape-recorded senior pediatric attendings, residents, and interns evaluating infants with fever.14 Nearly all tried to form a clinical impression of the infants’ overall health. However, what surprised us was the striking difference in their approaches to the infants. The advanced attendings formed their clinical impressions by talking and playing with the infants. One of the senior pediatricians we taped was Dr Fraad. First, he introduced himself to the mother and asked her to tell him briefly what was wrong with her baby. He
PEDIATRICS AND THE LURE OF TECHNOLOGY
5
acknowledged how hard it must have been for her to take care of a sick infant. In this way, he built rapport with the mother who would become his ally in figuring out what was wrong and what had to be done. Then he talked to the infant: “What’s the matter, baby, what’s the matter?” He repeated these and similar phrases as if the infant were an older child who could talk back. It seemed that he believed that an interaction with the child was vital. Another senior pediatrician, whom we called Physician 1 in our study, said, “Hello, cute baby, how are you? You are smiling at me and you’re looking me right in the eyes, so I’m not too worried about you, because you’re smiling so nicely..” This physician was forming a clinical impression through interpersonal interaction. In contrast, the interns and residents typically tried to form an impression from a detached, objective viewpoint. They checked off features of the babies’ appearance and behavior. For example, an intern, whom we called Physician 2, took a history from the mother and then said, I have observed that the child has been quiet the entire interview, which indicates that he may have been sick for several days. But he is alert and does respond to outside stimuli so his level of alertness is suggestive too. I notice he has nice large tears, which is indicative of a well-hydrated state. This small sample study, then, suggests that experienced physicians are more likely than trainees to form a clinical impression through warm, interpersonal interactions. McCarthy also found that experienced attendings were much more likely to form clinical impressions based on interaction with the patient and that these interaction-based impressions were the best predictors of serious illness.15 In a second study, we found support for the possibility that as medical students and physicians gain experience they increasingly come to appreciate the intuitive, interpersonal approach. We asked a wide range of respondents, including premedical students, first- and third-year medical students, pediatric interns, and senior residents to read the responses of Physicians 1 and 2 and to guess the physicians’ levels of experience. They were also asked to give the reasons for their guesses. The Figure summarizes the data as the percentages of each group of respondents who rated Physician 1 or Physician 2 as more advanced. The less experienced respondents—the premedical and the medical students— generally rated the interpersonal Physician 1 lower than the detached Physician 2. A majority in each of these groups guessed that Physician 1 was a mere beginner, explaining that Physician 1, lacking scientific knowledge, was relying on “physician appearances” and “vague impressions.” They thought Physician 1 was too personal, “not putting enough distance between himself and the patient.” Physician 2, they wrote, was more “professional” and “objective.” As one respondent wrote, “He uses detached, intellectual terms, which is the goal of medical training.” At the opposite extreme were the senior pediatric residents, who usually guessed that Physician 1 was an experienced attending physician forming an intuitive, sensory
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Figure. Bar graph showing results of respondents who rated Physician 1 or Physician 2 as the more advanced doctor. The percentages for each group do not always total 100 because a small number of respondents (
