The Illness of Present Histories

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Teaching the History and Physical is a sacred tradition in the medical curriculum. Yet, the pedagogy may be outdated and impractical in a world dominated by the electronic health record (EHR). The idyllic scenario of a student handcrafting a thorough history has been replaced by a digital scavenger hunt that reverse-engineers the initial patient encounter.
Our medical institution used paper charts. In many ways, this approach made it easier to synthesize information without the bombardment of data from an electronic record. As we began our internships at a new program, we were suddenly at the mercy of a complex EHR. Smartphrases, automated flowsheets, and copy-forwarded notes became the norm. It was difficult to discern what information was important and how it could be expediently found. Even before meeting a patient, the resident had already glanced at the patient’s discharge summaries and clinic notes while simultaneously reviewing the vitals, labs, and problem lists that had autopopulated the chart.
As attendings, we continue to see students struggle through this transition. There are five common symptoms:
To confront this, our students must receive thoughtful training that extends beyond online modules (which, ironically, are done in front of yet another computer). As we look to introduce students to authentic clinical experiences in their training, we must also remember to include direct physician oversight and give the necessary tools to combat these common symptoms. For better or worse, the EHR is here to stay. We can lament about how it can negatively affect patient perceptions of care and efficiency, but we cannot neglect our students and continue to allow them to struggle.
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