- physician–patient–parent relationship
- medical education
- COW —
- computer on wheels
How did I find myself leading family-centered rounds a while ago in the NICU, yet unable to actually see any of my team members, not to mention my patient’s parents sitting just several feet away? I looked up while listening to a summary of the infant’s overnight events, and suddenly it hit me, something was amiss. My entire team was hidden, our views obstructed, from each other and the patient’s family. No one was fully focused or making eye contact during the presentation. I could not see to whom the presenting voice belonged. One resident was fixated on the computer screen, while another was obliviously typing away, nose to keyboard. This hardly looked the picture of family-centered rounding, or the epitome of good communication, things I strived for. The humbling culprit, aside from me? COWs. No, not the grass-eating, milk-producing kind of cow, but rather the portable data-crunching COW, affectionately short for “computer on wheels.”
These mobile computing machines have now become permanent features of many hospitals and clinics, and for good reason. COWs help streamline and improve medical care, including electronic patient charting and documentation, increasingly onerous tasks. They allow physicians to, for example, quickly check on a laboratory result or write an admission note, while watching over a critical patient. COWs also help expedite clinic notes during back-to-back patient encounters. The COW certainly facilitates on-the-go charting, the new fast food of medical documentation for the multitasking physician. But, as I struggled with my own unwieldy machine during rounds, trying to find the optimal positioning for the albatross, I realized that COWs may also sometimes hinder effective communication and, thus, patient care.
Good communication is, of course, extremely important in medicine. It is the foundation of any successful physician–patient–parent relationship in pediatrics. A key component of effective communication with patients and their families involves active listening. As Sir William Osler (1849–1919), one of the founding fathers of modern medicine and medical education, famously advocated, “Listen to your patient, he is telling you the diagnosis…”1 Active listening requires focused attention, not fragmented between a COW and the patient and his family. Our patients deserve our undivided attention, especially given the limited time we have during each encounter. Effective communication also involves demonstration and verbalization of understanding after listening, often by summarizing or repeating what has been conveyed, and a reciprocal exchange of information between those involved.2 Finally, effective communication requires an environment with minimal distraction. This ideally results in a trusting physician–patient–parent relationship, an equal exchange of information between all parties, and shared decision-making.2
Excellence in communication, along with interpersonal skills, is accordingly highlighted as 1 of the 6 core competencies to be mastered by medical trainees per the Accreditation Council for Graduate Medical Education Outcome Project.3 Teaching this important, yet nebulous, skill to trainees has evolved significantly over the decades. Good communication is no longer only modeled by senior physicians, a practice that is indeed valuable, but inadequate alone. Effective communication is now actively taught to medical trainees via an array of evidence-based methods, including small-group case discussions, simulations with standardized patient actors, self-reflective learning, and videotaping with feedback. Modules also aim at teaching and improving critical communication skills during especially difficult situations, such as discussing a new diagnosis of cancer with an adolescent patient, or delivering bad news to the parents of a newborn in the NICU. However, none, to my knowledge, addresses good communication and the use of technology, such as COWs, in the clinical setting.
Mastery of effective communication skills results in several benefits for both patients and physicians. Patients and their families have a better understanding of their illness, prognosis, and treatment, and are thus more likely to follow physician recommendations, adhere to treatment regimens, and return for follow-up appointments.2,4 Patients are happier and more satisfied when they feel they are being listened to, when their complaints are heard. Similarly, physician satisfaction also increases. Physicians who effectively communicate report reduced levels of stress, perceive better relationships with their patients, and indicate greater job satisfaction overall.2 Good communication also improves certain patient health outcomes, such as emotional health, symptom resolution, function, pain control, and even physiologic measures like blood pressure or blood sugar.2 Fewer malpractice claims are filed against physicians excelling in communication by patients because of increased trust and patient satisfaction.2,5 Improved communication also helps mitigate error on a systems level, decreasing the risk of being sued. Although certainly not the primary goal of effective communication, this is a welcome benefit. Finally, mastery of communication allows physicians to be more effective teachers, for their patients and families, as well as for trainees.
Although obviously an overall technological benefit to medicine, COWs can also pose several problems that may lead to poor or ineffective communication, threatening to disrupt the benefits described above. COWs can literally create a physical obstruction to communication by preventing basic face-to-face dialogue and hindering nonverbal cues, such as eye contact. Whether rounding on the floor or seeing patients in the clinic with COWs, care should be taken to position the machines to ensure that all team members can clearly see each other, the patient, and the patient’s family if present. The smaller, more portable versions of COWs, such as electronic tablets and pads, are becoming popular in many institutions. Often seen cradled in 1 arm by a team member during rounds, or slipped into a generously sized white coat pocket, these devices are conveniently smaller and more mobile than their bulkier counterparts. As such, they are less likely to cause physical obstruction to communication with patients, families, and colleagues, but may still pose other communication disruptions.
COWs and other portable devices may also impede good communication via distraction. Distraction prohibits active listening, essential for effective communication, which also threatens professionalism as well. It may be tempting to multitask during rounds by writing a progress note, for example, but this only erodes both communication and professionalism. When used correctly, a COW may prove helpful during rounds without diminishing effective communication, for instance, to briefly verify a patient’s laboratory result to ensure accuracy when formulating a plan. During family-centered rounds, however, the team should be actively engaged and listening intently to the patient presentation or the family’s questions and concerns, not focused on the computer screen.
Likewise, given onerous daily documentation responsibilities, it is tempting to simultaneously listen to a patient’s or parent’s chief complaint and type in the electronic medical record by using a COW, occasionally nodding in response to questions, without actually engaging in active listening. This common distraction pitfall can easily disrupt or erode the physician–patient relationship and should obviously be avoided. Common sense, basic etiquette, and professionalism naturally advise you instead to pause at the keyboard, look your patient in the eyes, and then respond. A simple act such as this can do much to help establish good rapport and foster the human connection.
I am certainly not advocating a return to the pre-COW era of medicine. In fact, I applaud the incorporation of technology, in general, into clinical practice. I simply wish to gently encourage those using COWs, or other portable computers and tablets, in clinical settings to be cognizant of their potential for disrupting verbal and nonverbal communication. Certainly, studies assessing the effects of COWs on communication between health care teams, patients, and families would help guide potential solutions. Once armed with such needed data, perhaps medical training can include simulation modules emphasizing effective communication amid such technology. By working with technology (instead of behind it), physicians can further improve communication with their patients and, hence, the physician–patient–parent relationship.
- Accepted November 28, 2012.
- Address for correspondence to Christy L. Cummings, MD, Division of Newborn Medicine, Boston Children’s Hospital, 300 Longwood Ave, Hunnewell 437, Boston, MA 02115. E-mail:
FINANCIAL DISCLOSURE: The author has indicated that she has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
- Silverman ME,
- Murray TJ,
- Bryan CS
- ↵ACGME. Common Program Requirements: General Competencies. Chicago, IL: Accreditation Council of Graduate Medical Education; 2007:1–3. Available at: www.acgme.org/acWebsite/navPages/commonpr_documents/IVA5d_EducationalProgram_ACGMECompetencies_IPCS_Explanation.pdf. Accessed July 18, 2012
- Copyright © 2013 by the American Academy of Pediatrics