Re: The Use of Electronic Health Records in the Exam Room and Patient Satisfaction: A Systematic Review
In this issue of the JABFM, Irani et al1 systematically review recent studies on electronic health records (EHRs) in the examination room and patient satisfaction. The thing that stands out most to me as a practicing physician is the paucity of data that has directly examined this subject at a time when we are being pushed to adopt EHRs and other technology, while simultaneously being asked to be more efficient in our delivery of care. The element that is often left out of the initiatives of politicians and bureaucrats is the doctor–patient relationship. No amount of technological advancement can ultimately replace the basic function of the physician to comfort, and ultimately to heal, the patient before him or her. Without a systematic approach to determine what impact the adoption of technology is having on the therapeutic relationship, we must rightly fear betraying the principle to “Do no harm.” This article begins to delve into a synthesis of what information is available. The data that is available is on the whole encouraging, but seems incomplete. The authors make the excellent point that, despite the overall positive findings of the few studies available, more rigorous and extensive study is needed to definitively assess the impact of EHR adoption on the doctor–patient dyad. The changing face of modern medicine demands that we be ever vigilant for forces that come between the patient and the physician. To do anything less is to abandon the very foundation of medical care as we know it.
Re: The Decision to Intensify Therapy in Type 2 Diabetes: Results from an Experiment Using a Clinical Case Vignette
The article by Grant et al2 in this issue explores a simulated decision making process on intensification of therapy in a type 2 diabetic with marginal objective findings of control. The role of patient and physician demographic variables is examined, and the study failed to identify major demographic predictors of therapy intensification. Obviously the factors that affect therapeutic decision making are highly complex and differ in ways that are at times very subtle. Although the authors note that the ecological validity of vignettes to study medical decision making has been shown, this does not necessarily extend to imply the generalizability of the results. A limitation of this study that is concerning is the fact that it involved a relatively small number of physicians from a small geographic area. Perhaps a much larger study involving a national sample, perhaps using practice-based research networks, would be able to detect more subtle effects. Further, the comparison of data from different regions could yield valuable insight. Certainly further research to examine why we make the decisions we do as physicians is always a good idea. Socrates said, “The unexamined life is not worth living.” A corollary to that might be that the unexamined medical practice is certain to be less than optimal. We should certainly continue to pursue further research in this area, as our patients deserve nothing less than our best.
Re: Stepped Care Treatment of Postpartum Depression: Impact on Treatment and Health Outcomes
In a study of stepped care treatment of postpartum depression, Gjerdingen et al3 examine the impact of a collaborative care model on specified outcomes. The study shows promise of collaborative stepped care providing improved awareness of diagnosis and improved treatment rates. Unfortunately, this is overshadowed by the extent to which the formal diagnostic procedures missed many women impaired by problems with self-identified depression symptoms. This brings to the fore the limitations of some of our more institutionalized approaches to medicine and that diagnosis is often a complex and relational part of the practice of medicine. This may also serve as a caution against over delegation of diagnosis and evaluation. If all the patients affected by depression symptoms had been captured and randomized, the data in this study may have been much more robust, and more patients may have been positively affected. It is of interest to recognize that collaborative care, and the attendant need to optimize resource utilization by way of a stepped care approach, is likely to become a part of the medical landscape in the United States. This will be particularly true if health care funding becomes more stretched, and primary care and mental health shortages continue to loom in the future. It is important that there be ongoing research like that by Gjerdingen in order for us to know how to provide collaborative care effectively and without losing patients along the way.
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