Medical student Gregory Shumer studied the electronic health record and scooted his laptop closer to the diabetic grandfather sitting on his exam table. "You can see," he pointed at the screen - weight, blood sugar and cholesterol are too high and rising.
The man didn't reveal he was too nearsighted to see those numbers, but he'd quietly volunteered that he'd been ignoring his own health after his wife's death. The future-Dr. Shumer looked away from the computer for a sympathetic conversation - exactly the point of Georgetown University's novel training program.
As the nation moves to paperless medicine, doctors are grappling with an awkward challenge: How do they tap the promise of computers, smartphones and iPads in the exam room without losing the human connection with their patients? Are the gadgets a boon, or a distraction?
"That's the tension I feel every day," says Dr. Vincent WinklerPrins, a family medicine specialist at Georgetown. The medical school is developing one of a growing number of programs to train new doctors in that balancing act, this one using actors as patients to point out the pitfalls ahead of time.
Across the country at Stanford University this summer, medical students will bring a school-issued iPad along as they begin their bedside training - amid cautions not to get so lost in all the on-screen information that they pay too little attention to the actual patient.
Face your patient, excuse yourself to check the screen and put away the gadget when you don't really need it, say Stanford guidelines that specialists say make sense for physicians everywhere. And, of course, no personal Internet use in front of a patient.
"The promise of these devices to augment the delivery of clinical care is tremendous," says Stanford's Dr. Clarence Braddock. He uses a secure app on his iPad to pull up patient charts if he's called after hours no matter where he is.
Braddock helped develop Stanford's standards understanding there are different hurdles. Middle-aged doctors may be less comfortable with the technology and take longer with it. Younger ones who grew up texting while multitasking may not realize how intrusive patients might find the devices. Even Braddock has a confession: To his embarrassment, his phone once beeped an email alert about a sports tournament while he was with a patient.
It's not just a matter of etiquette. If the doctor spends too much of your 15-minute visit typing or staring at a screen, you have to wonder: What if I have a symptom that just got missed?
"If the screen is turned away from the patient, they don't know if you're looking at their electronic health record or playing solitaire or looking up stocks," notes Dr. Glen Stream of the American Academy of Family Physicians. A longtime user of computerized records in his Spokane, Wash., practice, Stream makes sure to show his patients what he's doing - especially when seeing pictures on the screen can help them better understand a health condition.
Electronic health records, or EHRs, are considered the future of health care for good reason - they can help prevent medical errors. For example, the systems can warn if doctors are about to prescribe a drug that could interact badly with another one the patient already uses. As these computerized charts become more sophisticated, they also have the potential to spur more efficient care: no more getting another X-ray just because you forgot to bring in your last scan if the doctor can call it up digitally.
About a third of doctors report using electronic records, double the number since 2008, says a report this month in the journal Health Affairs. Many more doctors are expected to adopt them by 2015 or face cuts in Medicare payments.
The challenge in the intimate exam room: Don't let the gadget distract from your main job, "which is helping patients with their lives," says Georgetown's WinklerPrins. He limits screen time in front of his own patients by typing notes into their charts after they leave.
Hence, the training for new doctors.
A group of actors gathered at Georgetown one recent morning, each there to play the role of an older diabetic seeking care for the first time since a spouse's death. WinklerPrins watched on a monitor outside the room as medical students conducted a 15-minute office visit. They used computerized records while giving each actor-patient test results, setting a treatment plan and sending an electronic prescription to the pharmacy.
Afterward, the "patients" offered valuable feedback. One was irritated that her would-be doctor got stuck e-prescribing and, her mind on the computer, kept repeating the same question rather than saying, "Give me a minute."
Down the hall, actor John Askew Sr. praised Shumer's bedside manner but explained the computer screen was too far away for him to see.
"If you said, 'Can you see?' I would have felt less disengaged," said Askew, from Washington's Maryland suburbs.
The students see the value of electronic health records but also how easy it is to be distracted with all the clicking and scrolling.
"When I have the computer, I may be less personable, but my notes are more thorough," Shumer, of Farmington Hills, Mich., told his professor. "It's easier to have a relationship when the computer is not there."
Hopefully, the systems will get less clunky, WinklerPrins responded: "We don't lose, in the meantime, the focus on the patient."