EDITORIAL
CURRENT
OPINION Practicing the art of medicine in the era
of technology
Travis T. Tollefson
From the beginning of our medical education, we
have been taught that practicing medicine and
healing is an art form. If you were hibernating for
the last few decades and awoke to the current era of
medical care, you might be surprised by the unin-
tended consequences of increasing technology to
the doctorpatient relationship. In medical school,
we learn to introduce ourselves with a handshake,
elicit a history, and physical examination. After this
examination, scans and other tests are chosen to
narrow our differential diagnosis. However, surgical
trainees are experiencing less continuity of care as
patient sign-outs and hand-offs are used to trans-
fer care because of shortened work hours. The rigors
of training and more shift work decrease the
exposure to the patients care process. This rapid
patient turnover may be linked to less emphasis on
the history and physical, and more reliance on the
data input into the electronic medical record (EMR).
It only gets worse when we are out in practice.
Doctors have encounters with patients that last
for 10 min, whereas EMR documentation takes more
than 30 min. The complexity of billing, coding, and
authorization processes requires a highly trained
office staff, just to stay on endless telephone
holds with insurers. Patients then rate their doctors
online, post their dissatisfaction on Facebook,
and identify the next doctor online who would be
willing to do their surgery with a cutting-edge robot.
Some physicians have mastered the EMR obligations
with medical scribes, smart phrases, and prepopu-
lated notes; but others are struggling as they
are asked to see more patients, in shortened visits,
with more typing and documentation.
HOW CAN WE RECONCILE THE ART, THE
SCIENCE AND TECHNOLOGY, AND THE
BUSINESS MODELS INTO A MODERN
MEDICAL PRACTICE?
Modern society behaves in daily life with less
attention span and rapid acquisition of information.
This translates to the modern doctorpatient visit in
many forms, which present a paradox to the model
of a physician as a listener and diagnostician. As
1068-9508 Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
physician educators, we must strive to embrace
the changes, while emphasizing the traditional ten-
ets of the doctorpatient visit with our trainees. A
few areas that we may accomplish this include:
emphasize the role of listening and observation as
a physician, mentoring, offering coursework on
the rapidly changing healthcare environment, and
engaging in research on the effect of new policies
on trainees and practicing physicians.
The most influential role models in my surgical
training were gifted and patient listeners, who we
should emulate for our trainees. They did not appear
rushed, sat eye level with the patient, and made
direct eye contact. Regardless of the length of
the visit, we can make the most impact by asking
open-ended questions. Although counterintuitive,
2 min of silent listening after posing an open-ended
question can efficiently target the patients true
concerns. In a hectic clinic, this is difficult but
can reduce the number of return visits and increase
patient satisfaction. Lastly, these mentors used
reflective listening to clarify the patients com-
plaints before offering solutions.
As mentors, we must emphasize the role of the
physical examination in all patients, whether or not
they have just been handed off from a prior shift.
Not uncommonly, the second history and examin-
ation gathers new information that guides care.
A common anecdote is relying on computed tom-
ography scans to make a diagnosis without a proper
physical examination. Although working in Rwanda
recently, I noticed that the student doctors were
quite skilled at physical examination in a facial
trauma patient. The treatment plan was devised
Facial Plastic and Reconstructive Surgery, Otolaryngology-Head and
Neck Surgery, Davis Medical Center, University of California, Sacra-
mento, California, USA
Correspondence to Travis T. Tollefson, MD, MPH, Professor and Director,
Facial Plastic and Reconstructive Surgery, Otolaryngology-Head and
Neck Surgery, University of California, Davis Medical Center, 2521
Stockton Blvd, Suite 7200, Sacramento, CA 95817, USA.
Tel: +1 916 734 2801; e-mail: tttollefson@ucdavis.edu
Curr Opin Otolaryngol Head Neck Surg 2016, 24:271272
DOI:10.1097/MOO.0000000000000281
www.co-otolaryngology.com
Facial plastic surgery
after the examination, with a computed tomogra-
phy scan used for those that may require surgery.
Our own trainees should be encouraged to do
the same.
Medical school and residency curriculums need
to include training in the business of medical prac-
tice and professional behavior. The shift to EMR has
task shifted much of the traditional coding and
billing to the physician, who should be armed with
the tools to receive appropriate payment for the
work performed. Training must include the legal
implications and professional behavior of using
social media in medicine.
Lastly, the practice of medicine has seen changes
from EMR, resident work hour restrictions, and
more shift-based schedules. Our own research must
be encouraged to identify those new policies and
processes that are detrimental to our profession.
Gawandes [1] daunting 2009 article on excessive
Medicare billings in Texas reminded us that we must
police ourselves [1]. We must collect our own data
how healthcare reforms affect patient quality and
safety and not rely on management, who may be
prone to see us as providers in the cogwheels of the
healthcare system.
In conclusion, in this rapidly evolving technol-
ogy-driven age, we must remember to practice and
teach the art of being a physician. In a recent lecture
by a leader in our field, the importance of the
doctorpatient visit was emphasized. He provided
evidence that the attitude of the physician affects
patient outcomes and advocated for the following:
(1) Consciously making physical contact with our
patients (as few as seven times),
(2) Investigating the patients concerns by asking
How and Why, not What, and
(3) Having the patience to let the patient speak for
2 min without interrupting.
Our trainees deserve good role models in the
clinic and operating rooms. The modern doctor
patient relationship is evolving with cost-cutting
goals of affordable care. Many are warranted,
but as Gawande remarks . . . not all quality can
be measured. Its possible that we will calibrate
things wrongly, and skate past the point where
272 www.co-otolaryngology.com
Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
conservative care becomes inadequate care [2].
We must teach, mentor, and engage in healthcare
delivery research to iteratively improve our proc-
esses, for our patients and ourselves. Otherwise,
policy makers, insurers, and management will
control our destiny.
In this edition of Current Opinion of Otolaryngol-
ogy Head and Neck Surgery, contributions on rhi-
noplasty have been collected from esteemed
international authors. Freire et al. (pp. 316321)
from Brazil present the updates to alar base
reduction. Ozucer et al. (pp. 309315) from Turkey
review current nasal bone reshaping philosophies,
whereas Jun Lee and Jang (pp. 294299) from Korea
provide a review of repairing saddle nose and
short-nose deformities. Fedok (USA; pp. 279284)
updates us on middle nasal vault surgeries. Within
the facial trauma field, Weiss and Sawhney
(pp. 273278) review the controversial topic of
mandibular condyle fractures. From the basic
science realm, Wang and Pepper (pp. 285293)
present the state of the science of stem cell-mediated
therapies for facial nerve injuries. The management
of nasal Mohs defects is outlined by Moses and
Woodard (pp. 300308) after a literature review
from the journals of the multiple specialties
involved. The issue is concluded with Del Toro
et al.s (pp. 322329) extensive review of the current
management strategies for preventing and treating
postsurgical facial scars, a topic that is relevant to
surgeons of any type. I hope you enjoy this edition
and welcome your recommendations for future
reviews.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Gawande A. The cost conundrum. The New Yorker, June 1, 2009.
2. Gawande A. Overkill. The New Yorker, May 11, 2015.
Volume 24  Number 4  August 2016