Here’s a simulated doctor patient consultation that took place today at the Royal Society of Medicine. A 65 year old woman (cunningly disguised as a bald, male professor from the Mayo Clinic) who is known to be hypertensive and on treatment says that her blood pressure has gone up over the last 10 days. An Australian doctor plucked from the crowd starts the consultation.
“Why do you think your blood pressure might have gone up?”
“I don’t know.”
“Has anything changed in your life.”
“I don’t think so.”
“Are you under any stress?”
“Is everything OK at home?”
“Have you changed your diet?”
“Have you been taking any new medicines?”
“It may not mean anything. Your blood pressure isn’t that high. Keep measuring your blood pressure. Let me know if it increases suddenly. Otherwise, come back in two weeks.”
This case is based on a real one, and the patient had given her history to a computer before seeing the doctor. The computer – which never tires, has unlimited time, and can ask prepared questions in a way that doctors often don’t remember – had elicited all that the doctor elicited and much more. In particular it had asked about known but rare causes of raised blood pressure and had discovered that over the past 10 days the women had been eating imported licorice. She didn’t tell the doctor because it never occurred to her that it could be important.
In the real case the doctor knew that licorice could have this effect – and it leapt out at him when he scanned the summary of the history taken by the computer. Doctors are good and fast at scanning such histories to pick out the crucial facts, which is why a partnership of computers and doctors can be so potent.
One reason that computers take better medical histories than doctors is that doctors do it badly. Doctors, said Professor John Bachman from the Mayo Clinic at an RSM conference on Using the Internet to Practice Medicine, use jargon and miss 50% of psychoscial psychiatric problems. Studies at the Mayo Clinic, indisputably one of the world’s leading clinics, show that they miss 54% of patient problems and 45% of patient concerns. In half of consultations the doctors and patients did not agree on the presenting complaint. Doctors do, of course, have limited time, although the Mayo doctors consulted for 30 minutes.
Computer interviews are structured and provide more complete data than interviews by doctors. Many studies have shown this. Computer interviews can be done at the patient’s pace, and most patients like computer interviews. Patients will also tell computers things that they won’t tell doctors, even though they know that the doctors will see what they have told the computer. Plus the computer records exactly what the patient says, and it’s easy to incorporate validated scales into the questioning.
Dr Allen Wenner, a consultant physician from South Carolina and one of the pioneers of the use of computer interviews, told the story of a middle aged man who filled in the MAST questionnaire for alcohol problems and scored in the “alcoholic” range. Wenner was able to point this out to the patient, something less judgemental than him saying to the patient “I think that you may be an alcoholic.” Nevertheless, the patient was furious and told his wife that he would never consult Wenner again.
But another advantage of computer interviews is that the doctor can give a copy to the patient as well as keep a copy in the electronic patient record. The man took home his interview, and later his wife asked him about the consultation. She pointed out to her husband that it was him that had given the information that suggested he was an alcoholic. It wasn’t a judgement of Wenner. Given time the man came round to the idea that he needed to do something about his drinking, and returned to Wenner.
Computers can also interview family members, have no problems with different languages, don’t get impatient, can use multimedia, and provide marvellous data for research.
Almost everything I’ve written so far was known in the 60s, and it was all in an editorial in the BMJ in 1988 written by Mike Pringle, who subsequently became chairman of the council of the Royal College of General Practitioners.
Yet computers are hardly used in Britain for taking histories, although they do begin to be used more in the US.
Why? The answer seems to be that we don’t change until we have to, and we haven’t yet had to. It may be, however, that financial cuts in the NHS will force change in a way that generous funding of the NHS has not. And help is at hand – from people affected by thalidomide. The Thalidomide Trust helped organise the meeting – because people affected by thalidomide get a raw deal from the NHS and are desperate to find better ways. Consultations through the internet incorporating computer histories could be one of those ways.
Competing interests: Richard Smith is the chair of Patients Know Best, a start up business that aims to use information technology to enhance the clinician patient relationship. I am not paid but have some equity. The company has a contract with the Thalidomide Trust.
Richard Smith is a former editor of the BMJ.