Under My Skin

When the iPad is on the other foot


Sometimes patients take a few notes when I talk, but Niles was different. As I started to spout words of wisdom about his granuloma annulare, he whipped out a tablet and started to type.

“How do you spell that again?” he wanted to know.

I spelled it out, and Niles tapped away. I launched into my usual explanation – how the cause is unknown, how it is roundish but not a fungus, how it usually has no systemic significance, and so on. At each point, looking down at the keyboard, he stopped me.

Dr. Alan Rockoff

Dr. Alan Rockoff

“Wait, you say it isn’t fungal?”

“No ...”

Typing. “And you don’t know the cause?”

“No, the medical term for that is ‘idiopathic’ ...”

“Wait, how do you spell that?”

I regretted using the word. “I-D-I-O-P-A-T-H-I-C.”

More typing. “Wait, hold on. OK, got it. And what did you say you want to treat it with?”

“A cream. Betamethasone dipropionate.”

“Hold on! How do you spell that?”

I spelled it out, along with “augmented” and “0.05%.”

The interview continued a bit longer. As we concluded, Niles thanked me for seeing him. At no time did he raise his eyes from the tablet, even as he was putting it back into its case. He acted the same way my staff does when I walk into the lunchroom. There I see three or four people sitting around a table with a sandwich or salad in front of them, staring at their smartphones. The same way groups of people do nowadays, everywhere. (A couple of years ago, I took some of my grandchildren out on a rowboat on the Charles River on a sunny summer afternoon. There we saw two young women, oars across their laps, examining their phones.)

People sitting on a bench look at their smartphones. Michele G. Sullivan/Frontline Medical News

When my student and I left the room, I took him aside.

“Did you see anything unusual about how that visit went?” I asked.

When he looked blank, I explained: “The patient didn’t look me in the eye once.”

Yes, come to think of it, the student had noticed that.

“Not very satisfying, was it?” I asked. “It’s hard to talk to somebody who isn’t looking at you. It’s even a little insulting, don’t you think?” He agreed.

“When you’re out in practice in a few years,” I said, “the person in the exam room looking at the computer and not making eye contact is likely to be you. Think about how it felt to watch me talking at the top of the patient’s head, and then imagine how your patients are likely to feel when they’re talking to the top of your head. Unless of course your laptop has a screen that blocks your head altogether.

“I just bring a clipboard with sheets of paper on it into the exam room,” I said. “The way things are working out, I think I’ll be able to make it to the end of my career without being forced to use an electronic device.

“You have your whole career ahead of you, though,” I told him. “I guess you’ll figure out how to make communication work.”

He will too, no doubt. He’ll have to. As the Romans used to say, times change, and we change with them.

No need to spell this out for the younger generation, literally or otherwise.

Just a short addendum from the world of artificial intelligence, as applied to voice recognition software:

Last week I saw Chad, who had seen my colleague a year earlier and come back for a skin check. She had described Chad’s occupation:

“The patient is a flight attendant for Diflucan Airlines.”

Check them out. Their restrooms are so clean you can go barefoot.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected].

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