In 1816 René Laennec, a physician at the Necker Hospital in Paris, was consulted by a young woman with the general symptoms of a diseased heart. The examination he had been taught served him badly. Her build made percussion, the tapping of the chest, of little use, and the same was true of a hand laid flat over the heart. The remaining method, pressing his ear directly against her chest, he judged inadmissible in a young woman. He then recalled what he called a simple and well-known fact of acoustics: put an ear to one end of a wooden beam, and the scratch of a pin at the far end comes through distinctly. He rolled a quire of paper into a tight cylinder, set one end over her heart and the other to his ear, and heard the heart, he wrote afterwards, more clearly and distinctly than he had ever heard it with the ear alone. By his own account he was surprised and pleased.
The rest is the part of the story usually told too quickly. Laennec was a capable wood-turner, and he went on to make the cylinder in wood, with a narrow channel bored down its length. Then came three years of slow, unglamorous work: listening at the bedsides of the Necker’s patients, many of them consumptive, and following those who died to the post-mortem table, where he could hold up what he had heard against what the lung or heart actually showed. The treatise that came of it in 1819 bore a title that gave the method its name, De l’auscultation médiate, and it gave students words they still learn: pectoriloquy, the voice that seems to speak straight out of the chest wall, and egophony, the bleating quality a voice takes on when it is heard through fluid. He called the instrument a stethoscope, from the Greek for chest and for looking or examining, so that a tool for listening entered medicine under a name for seeing. He died in 1826, of the tuberculosis whose signs he had done so much to describe.
The title is worth a moment. Immediate auscultation was the older practice, as old at least as the Hippocratic writings: the ear laid against the body with nothing in between. Mediate auscultation was listening by means of something placed between, and the adjective shares its root with medium, media and intermediary. Medicine has been setting objects between doctors and patients ever since, and Laennec, to his credit, chose a word that admitted it.
What made the paper tube a good intermediary, to my mind, was the direction it pointed. Both of its ends touched a person. However stiff the arrangement, the physician leaned toward the patient, and the instrument carried his attention into the body in front of him. The computer is an intermediary of another kind. The HITECH Act of 2009 offered American physicians incentive payments for adopting electronic records, and in the decade that followed, my first decade of practice in California, a screen became as standard in the examination room as the paper on the table. It also sits between. But it points elsewhere: toward the record, toward the patient’s past, toward the observations and requirements of people who are not in the room. That is enormously useful. It also gives a physician’s eyes a new place to go in the middle of a conversation, and rooms were not always arranged with that in mind.
This essay is about that second intermediary and the room it entered. The question I want to ask is narrower than whether computers belong in examination rooms, which they now plainly do, and wider than where the monitor should stand. When something comes between two people, what lets it serve their conversation instead of quietly taking it over? And can the person in the patient’s chair tell which of those it is doing?
Silence, Please #
It would be pleasant to leave Laennec as the hero of a simple parable, the good instrument against which the bad one can be measured. The history does not allow it. The historian Stanley Joel Reiser, in Medicine and the Reign of Technology (1978), read the stethoscope as the beginning of a long shift in medicine’s trust: away from what patients said about their illnesses and toward what instruments could detect in their bodies. A physician who could hear a cavity in the lung needed the patient’s account of her cough a little less. The sign began to outrank the story, and the instruments that followed pushed in the same direction.
There is a smaller and more physical version of the same point, familiar to anyone who has used a stethoscope. Auscultation requires silence. The patient is asked to stop talking and breathe through her mouth, and if she begins to say something while the chestpiece is on her skin, the physician raises a hand or asks her to hold the thought. For those seconds the instrument does not merely mediate the conversation; it suspends it. Laennec’s tube, in other words, also came between doctor and patient, and it did so by putting the patient’s words on hold.
Why, then, does the stethoscope still seem to me the better-behaved intermediary? Not because it is innocent. Because its purpose is legible. The patient can see where it points: at her. She knows roughly what it is for, she can feel when it begins, and she knows when it ends, because the doctor takes it out of his ears and starts talking again. The silence it imposes is bounded, and explained by the object itself. The screen differs on every one of these counts. It does not point at her. Its purpose is not visible from her chair. It does not begin or end; it glows through the whole visit. And whatever it is showing, she usually cannot see it. If one thread runs through what follows, it is this difference between an intermediary whose work the patient can read and one whose work she has to guess.
A Crowd Behind the Glass #
Part of what the patient is guessing at is who the screen is for. A stethoscope has one listener. A clinical record has many readers, and most of them are absent.
There is the clinician now, trying to understand the visit as it happens. There is the colleague who will cover on a weekend, the specialist who will receive a referral, the emergency physician who may open the chart at two in the morning with ninety seconds to spare. There is the patient herself, who can now generally read her own notes after the visit. There are readers who do not care about her as a person at all, and need not: the coder translating the visit into billable categories, the payer deciding whether to pay, the quality program counting whether a screening test was offered, the auditor, the researcher who will meet her only as a row in a table. And there is the clinician months later, a stranger by then to his own reasoning, who will need the note to tell him what he was thinking.
So when a physician’s eyes go to the screen, they go to one of several places. Sometimes they return to the person in the chair by a longer route: her results, her old letters, the history she gave a colleague two years ago. Sometimes they go to an absent reader, to a field that must be completed or a box that must be ticked before the visit can be closed. From the chair the two look identical. A head turns; a hand moves; the patient waits.
English has a word for the object that is better than it knows. Monitor comes from the Latin monere, to remind or to warn, and a monitor was first a person who did that: an adviser, an overseer, in schools the pupil set to keep the others in order. The thing on the desk is well named. It reminds the doctor of the past and warns him of what is due. It is also a reminder, to anyone sitting in the room, that the room is not the whole audience.
None of this means that every glance at the screen is a desertion, or that every patient experiences it as one. Some interruptions come from the software and its demands. Some come from the physician’s own curiosity or habit. Some are requested by the patient, who asks what her cholesterol was last year and wants the answer, not a lecture on attention. In an observational study published in 2011, researchers in Australian general practice videotaped 141 consultations with twenty doctors and watched how patients themselves responded to the computer. Some watched the screen; some ignored it; some excluded it from the conversation altogether. Some consultations remained a matter of two people. Others became three-way affairs, in which patients drew the doctor’s attention to the screen and used what was on it to question what the doctor had said. The machine changes the room for both people, and both people answer it.
Drawing the Room #
Rooms answer first, before anyone speaks, and it helps to draw two of them in words. Both are imagined; neither describes a real room.
In the first, the desk runs along one wall and the monitor stands on it, facing that wall. The keyboard is fixed in front of the monitor. The patient’s chair is by the door, behind and to one side of the clinician’s, and the examination table runs along the far wall. To read or type, the clinician must turn a shoulder toward the screen and then, for any sustained work, most of his back. The patient’s line of sight runs to the side of his head and past it to the glow of a display whose content she cannot read but whose light she can see changing. When he wants to look at her, he swivels; when he wants the record, he swivels back. The visit becomes a sequence of rotations, and every rotation is a small public announcement of where the doctor’s attention has gone.
Punjabi has an idiom for one of those rotations. To turn the face away from someone, ਮੂੰਹ ਫੇਰਨਾ (munh pherna), is to withdraw from them: to refuse, to snub, to stop being available. The furniture of the first room makes the clinician perform that idiom literally a dozen times in twenty minutes without meaning a word of it. A patient who grew up with the idiom, or with any of its cousins in other languages, is not being oversensitive when she notices.
In the second room the chairs are set at an angle to one another, and the screen hangs on an arm at the apex of the triangle they make, so that the clinician can move from face to screen with his eyes alone, and the patient can at least see which way the screen is turned. The arm swings. When a graph or a letter is worth seeing, the display can be brought toward the middle of the room, where both people can look at it. The keyboard sits on a tray that moves with it. Nothing in the second room guarantees attention; a clinician can ignore a patient perfectly well from any angle. But the second room makes one kind of attention cheaper than the first room does, and over a working day, cheap things happen more often.
It would be easy to stop there and declare the second room the right one. Real rooms resist the drawing. Many examination rooms are barely large enough for a table, two chairs and the turning circle of a wheelchair, and the monitor goes where the outlet and the wall permit. A patient who uses a wheelchair cannot move to the screen; the screen has to come to her, or the information has to reach her some other way. A patient who is hard of hearing may depend on seeing the speaker’s lips, and for him every sentence spoken toward the monitor is a sentence partly lost; the years of masks made that dependence visible to many people who had never considered it. A patient with low vision cannot use a turned screen at its ordinary size and may need the text enlarged, read aloud or printed. An interpreter turns the triangle into a square, and someone has to decide whose eyes the patient should be meeting: the clinician’s, or those of the person whose voice she understands. When the interpreter appears by video on a tablet, the room acquires a second screen, and this one carries a face, so that the patient is now asked to look into a display in order to be understood. A parent with a small child on the examination table has her eyes on the child, not on anyone’s monitor.
None of these people is an exception to the design. Together they are a large part of the population a primary care room serves. The useful question is therefore not what the ideal layout would be. It is one that can be put to any layout: where does the person sit in relation to the work being done about her, and can she see it, reach it, hear it, or refuse it?
Attention Felt and Attention Shown #
The hardest thing about the screen, to my mind, is that attention felt and attention shown are different things, and the screen widens the gap between them.
Consider a hypothetical moment. A woman has come about her knees. Near the end of a long answer she mentions, almost in passing, that she has been taking a pain reliever bought over the counter every day for months. The physician turns to the screen and begins to scroll back through a year of laboratory results, looking for a blood test from the spring that her remark has suddenly made important. From inside, this is the most attentive moment of the visit. Her sentence changed what he needed to know, and he is acting on it at once. From outside, the sequence is simpler: she said something, and he turned away and started reading.
Neither person is mistaken. The physician is not imagining his attention, and the patient is not imagining its absence. They are describing the same thirty seconds from two positions in the room. Typing and scrolling are visible work. Listening and thinking are nearly invisible, and they grow more invisible still when the listener’s eyes are elsewhere. The thought that joined her sentence to the result from the spring happened entirely behind his face, and his face was turned to the wall.
What closes the gap is not mysterious. It is a sentence or two. What you just said about the tablets matters. I’m looking for a blood test from the spring. Said aloud, those words turn a profile back into part of the conversation, and they do something more: they tell her that her remark was heard, and that it had consequences. A second step, where it helps, is to turn the screen and let her see the result arrive. A third is to say afterwards what it means. The work was the same in both versions of the moment. Only one version let her see it.
The advice usually offered in response to all this is some version of always make eye contact, and I have little faith in it as a rule. Unbroken eye contact is not a universal comfort. Norms about where to look differ across cultures, generations and temperaments; for some people a steady gaze from someone in authority is a pressure, not a kindness, and some find sustained eye contact uncomfortable for reasons that have nothing to do with how far they trust the person in front of them. Some things are easier to say to a person who is looking at something else. Anyone who has had a hard conversation side by side in a car, or across a task done together, knows that being watched can make speech more difficult. A screen, used well, can offer that relief. It gives someone a place to rest her eyes while she says the sentence she came to say.
Here Emmanuel Levinas is more useful to me than the communication manuals, though he wrote nothing about examination rooms. In Totality and Infinity (1961) he placed the face of the other person at the origin of ethics. The face, for him, is not an object among other objects, to be examined as a chest is examined; it is an address, a summons that reaches me before I know anything about the person and places me under obligation simply by appearing. The idea is demanding and easily sentimentalised, and Levinas guarded against the sentimental version. In the radio conversations later published as Ethics and Infinity (1982), he remarked that the best way to meet another person is not even to notice the colour of his eyes. The face in his sense is not a surface. Attention to it cannot be measured in seconds of gaze.
That helps me say what the screen actually threatens. It is not the eyes. It is the answerability of the conversation: whether what the patient says can still reach the clinician and change what he does. A physician can look steadily into a patient’s eyes while her words fall into a template and go unanswered, and he can glance at a screen a hundred times in a visit in which every one of her sentences lands and is acted upon. The useful measure is closer to the second. It asks whether she can tell that she has been heard. Eye contact is one way of telling her. A sentence that joins her words to his next action is another, and it has the advantage that she can check it.
There is a pleasing accident in the vocabulary. Interface, the word we now use for the screen’s working surface, began as a nineteenth-century coinage of the physical sciences for the boundary where two bodies of matter meet. It has face inside it, as it should. The question is whether the boundary keeps the two bodies on either side apart, or lets something pass between them.
The Patient at the Display #
Turning the screen toward the patient is the obvious remedy, and a good one. A graph of a single number over five years, the picture a report describes, the letter a specialist sent: brought to the middle of the room, any of these becomes a third thing that two people look at together, the way two travellers bend over one map. The grammar of the record changes. It stops being something written about the patient out of her sight and becomes something consulted with her.
But turning the screen is an invitation, and an invitation is not the end of the work. A display built for a clinician is full of things that make sense only to someone who already knows what to ignore. There are abbreviations. There are old entries no one has removed, competing dates, results flagged in red or marked with an H because the software was designed to catch a busy clinician’s eye, and it will catch a patient’s heart just as readily. A value a hair outside its reference range can look, in red, like an emergency. Sharing such a display without explanation can move the barrier from the furniture into interpretation. Both people can now see the same thing and still be looking at different meanings.
Consider a hypothetical medication list, turned so that both people can read it. The physician sees a set of entries to reconcile. The patient sees a medicine she stopped taking months ago, still listed, and wonders whether anyone heard her when she said so. The useful moment is not the rotation of the monitor. It is the conversation the rotation permits: which of these are you actually taking, which have changed, and what should this list say now? The turned screen has made the record correctable in the presence of the one person most likely to know where it is wrong. A list kept in the physician’s head, or on a card in his pocket, never offered her quite that chance.
The invitation also needs an exit. Someone may prefer to have the plan explained aloud. She may need larger text, or find a graph more confusing than a sentence, or simply wish to keep talking without joining the physician at the screen. Some people do not want to see a particular trend, a weight curve drawn across five years in a single line, say, and they are entitled not to. Participation should not become one more task a patient must perform to prove she is engaged. Would you like to see this, or shall I tell you what it shows? offers the screen without imposing it.
I would judge the arrangement by one test: does it make disagreement easier to express? Can the patient point to an entry and say that it is wrong? Can the physician explain why something appears there without defending it merely because the system displays it? A shared screen earns its place when it helps both people revise the account together. It fails, however handsomely mounted, when the patient is shown her record the way a visitor is shown a document under glass.
Who Else Can See #
The shared screen has a privacy problem that the room’s geometry hides until the moment of turning. A display is not selective unless someone makes it so.
Imagine, again hypothetically, an older man who has come with his adult daughter, who drove him and who will help him carry out the plan. The physician swings the screen round to show him a result. Also visible, in a column nobody chose, are a diagnosis from a decade ago that he has never discussed with his children, the name of a medicine that tells its own story to anyone who recognises it, and the heading of a note from a specialty he would rather keep to himself. None of this was secret from the record. All of it was private from his daughter. The turn of a monitor made a disclosure that no one decided to make.
There are quieter versions of the same problem. Many clinical displays carry, at their edges, the ordinary traffic of a clinician’s working day: a count of waiting messages, a schedule with other patients’ names, an alert that appears about someone else’s result. A patient who leans in to look at her own chart may read a stranger’s name. The remedy is simple to state and easy to forget: look at the screen before turning it, and close what should not be seen.
The law gives this negotiation a frame without settling it. As I understand the federal privacy rule, a clinician may generally discuss a patient’s care in front of a family member or friend the patient has brought along, when the patient has had the chance to object and has not, and the rule tolerates the incidental glimpses that a reasonably careful practice cannot entirely prevent. Neither permission makes the patient’s preference irrelevant. Being allowed to show a screen in front of a companion is not the same as being asked to. The courteous course is to ask, and to ask in a way that leaves room for a no: Is it all right if we look at this together, with your daughter here? Some questions are better asked when the companion has stepped out to move the car.
The patient’s control has a second dimension, which is what she does not want to see. A trend she finds discouraging; a word in an old report that frightened her the first time she read it; an entry about an event she has spent years putting behind her. A practice that treats every shared display as an automatic good overrides those choices as surely as a practice of concealment would override her right to know. Sharing the screen is a practice to be negotiated, visit by visit, and not a virtue to be performed.
When the Hands Should Stop #
Most of what happens at the keyboard during a visit is neither good nor bad in itself. It depends on the moment, and the useful skill is noticing which moment it is.
Sometimes typing helps the conversation. A clinician who records a patient’s exact words, a band across my chest when I climb the stairs, preserves her language instead of translating it at once into a category, and the record is better for keeping her sentence. Typing the plan while saying it aloud, so that she can answer no, the other pharmacy or I already tried that, makes the note a joint document. Entering an order while she watches tells her that it has actually happened, which matters to anyone who has waited for a referral that was promised and never sent.
Sometimes typing is neutral: confirming an address, updating a pharmacy, the clerical small talk of any appointment, which most people expect and few resent.
And sometimes typing is a small act of absence. When someone begins to cry. When a sentence starts There’s something else and then stops. When the subject turns to a death, or to a fear the patient has carried for weeks, or to something she is ashamed of. At those moments the clatter of keys tells her that her words are being processed, and the processing can wait. The signals are not hard to read once one looks for them: a sentence that trails off, eyes that go to the keyboard and back, a voice that drops, a pause left open for the typing to finish. The response is not a rule either. Hands off the keys, the chair turned, the screen left alone for a minute, and the note written afterwards, which costs time later and is often worth it.
William Carlos Williams, a general practitioner in Rutherford, New Jersey, for some four decades, who wrote poems in the gaps between patients, described in his Autobiography (1951) a typewriter fastened to a leaf of his office desk. Given five or ten minutes, he could swing it up and work; when a patient came through the door, it went back down into the desk. The detail strikes me as a portrait of a well-behaved machine: present, ready, and built to disappear when someone entered who had a better claim on the doctor’s attention.
The monitor does not fold into the desk. But the gesture survives in smaller forms: hands lifted from the keyboard and rested in the lap, a laptop half closed, a chair turned away from the screen and toward the person. A visible withdrawal of the machine says, without a word, that the room now belongs to her. Some practices go further and take the keyboard out of the clinician’s hands entirely, with a human scribe or with software that listens and drafts the note. Those arrangements remove the noise of the hands. They do not answer the screen’s other questions: where the eyes go, who the record is for, and whether the patient can see what is being written about her.
What Furniture Can Fix #
It helps to sort the remedies by level, because each level fixes its own failures and not the others’.
Furniture is the cheapest: where the chairs go, whether the monitor sits on an arm, whether the examination table forces the clinician’s back toward the patient. Hardware comes next: a second display that faces the patient, a larger screen, a privacy filter, a tablet that can be passed across the room. Then software: a patient-facing view that hides the message count and other people’s names, text that can be enlarged, labels in plain language, alerts that can be held back during a visit. Then staffing: who reconciles the medication list before the clinician arrives, who updates the address, who handles the forms, so that the minutes in the room go to the parts only the clinician can do. Last, and least visible, come habits of communication: the narration, the asking, the pause.
The mistake is to expect one level to compensate for another. Rearranging a monitor does not relieve time pressure. If a visit lasts twenty minutes and the record claims a third of them, no angle of the screen will make that arithmetic kind. Nor can warmth compensate for an interface that hides the one result a clinician needs behind seven clicks; a kind physician lost in menus is still lost, and the patient watches him get lost. The opposite errors are as common. A well-designed display does not make an inattentive clinician attentive, and a generous staffing model can be squandered by a habit of typing through every confidence. A monitor arm is not a staffing model, and a staffing model is not a manner.
I offer none of this as a design standard. Observational studies describe what happens in these rooms more readily than they prove which arrangement would work better, and much of the advice on the subject is sensible principle rather than measured effect. What can be said with some confidence is modest: rooms make certain behaviours cheaper and others dearer, and people under pressure tend to do the cheap thing. That is reason enough to arrange the cheap thing well.
The Case for the Screen #
The screen deserves a fairer hearing than I have given it so far.
Many patients want what the screen provides far more than they want a doctor’s unbroken gaze: an accurate record, information that can be found, a result retrieved in seconds instead of promised by telephone next week. The paper era had attentive eyes and lost results. A physician could look at a patient with complete attention and forget the allergy she had mentioned at the previous visit, because the folder was in another building. A patient who has once been harmed by something that was not written down, or not found, may be reassured by the sound of typing. To her it is the sound of being taken down accurately. The keyboard is a promise that what she said will still exist tomorrow.
Others actively want the screen used. What did the specialist say? When was my last scan? Is that the same number as last time? They expect the physician to look things up, and would be puzzled by a doctor who refused to turn away from them long enough to do it. In the Australian study, some patients used the screen as a lever, drawing the doctor’s attention to it and questioning what he had said in light of what it showed. The record on the desk had given them something to argue with. And the record does not end with the visit. Many patients can read it later at home, which makes it a witness to the conversation that both parties can consult.
This case is right, and it should change how the original complaint is put. Eye contact is a poor proxy for care, and no posture is a measure of empathy. A doctor typing may be doing exactly what the patient most wants done. What survives the counterargument is narrower than the familiar lament, and more useful. The patient should be able to tell what the screen is doing for her, and she should be able to enter that work, or decline it, on her own terms. A screen that serves her and says so passes. A screen that serves her silently may pass in fact and fail in experience, which is a failure worth fixing. A screen that serves only the absent readers, while she watches the side of a head, fails on both counts.
A Room That Explains Itself #
Nostalgia for an examination room without equipment would be misplaced, because there never was one. Laennec’s tube joined the percussing fingers, and in time the head mirror, the ophthalmoscope, the reflex hammer and the blood-pressure cuff joined them; every generation of the consulting room has had its instruments between people. The question has always been how they are used, and whether the person on the other side can understand what they are for.
If I set myself a standard, it is one of transparency and responsiveness rather than posture. Say what I am looking at, and why. Look at the screen before turning it, and ask before turning it in front of anyone else. Offer the display; do not require it. Take the hands off the keys when the conversation changes, and turn the chair. Let the record be corrected in the room, by the person it describes, when she can see where it is wrong. None of these fits every visit. Each is a way of making the intermediary’s work legible to the person on the far side of it.
Laennec gave a listening instrument a name for looking, and it served because it carried the doctor’s attention into the person, and its purpose was plain from where she lay. The screen is a looking instrument through and through. The work of the room is to make it listen: to let what the patient says reach it and change it while she watches. The stethoscope had two ends and a person at each. The screen has only one face. Its other end, if it is to have one, is a sentence spoken across the room: here is what I am looking at, and here is why. Once that sentence has been said, the computer still sits between doctor and patient. It sits there as the paper tube did, as something both of them can account for.
Evidence and Editorial Note #
Documented findings. The essay relies on one fact from the author’s public biography: practice in California since 2010. Laennec’s 1816 consultation at the Necker Hospital (the young woman with symptoms of heart disease, percussion and the hand of little use, immediate auscultation judged inadmissible, the recalled acoustic fact of the pin and the wooden beam, the rolled paper cylinder), his wooden instrument, his clinico-pathological method, the 1819 treatise De l’auscultation médiate, the terms pectoriloquy and egophony, the Greek derivation of stethoscope, and his death from tuberculosis in 1826: Laennec’s own account as rendered in John Forbes’s English translation (1821) and standard histories of medicine, including the Linda Hall Library’s account of Laennec; the account is paraphrased, not quoted. Stanley Joel Reiser’s argument in Medicine and the Reign of Technology (Cambridge University Press, 1978) that the stethoscope began a shift of trust from the patient’s account toward instrument-detected signs: paraphrased from standard knowledge of the book. The HITECH Act of 2009 and its incentive payments for adopting electronic health records: standard knowledge. The Latin root of monitor and the nineteenth-century scientific origin of interface: standard dictionaries. The observational study of 141 videotaped consultations with twenty general practitioners in Australia, describing patients’ screen watching, ignoring and excluding, and two-party and three-party consultations: Pearce, Arnold, Phillips, Trumble and Dwan, Journal of the American Medical Informatics Association, 2011. Emmanuel Levinas, Totality and Infinity (1961), and the remark about the colour of the eyes in Ethics and Infinity (1982): paraphrased from standard knowledge; no quotation is given. William Carlos Williams’s medical practice in Rutherford, New Jersey, and the desk typewriter described in The Autobiography of William Carlos Williams (1951): paraphrased from standard knowledge. The HIPAA Privacy Rule’s provisions for sharing information with family members or friends involved in a patient’s care when the patient has the opportunity to object (45 CFR 164.510(b)) and for incidental uses and disclosures: stated in general terms from standard knowledge; this is not legal advice. The Punjabi idiom ਮੂੰਹ ਫੇਰਨਾ: standard usage. Vendor representations. None. The computer, screen, record, scribe and listening software are discussed generically.
Recollection and tradition. That the author has practised in California since 2010 is part of his published biography. The two rooms, the woman with the pain reliever, the shared medication list, and the older man with his daughter are hypothetical and illustrative; they do not describe any real room, clinic, facility, patient or visit, and no remembered scene is asserted. The remarks on eye contact, side-by-side conversation and typing are general observations, not accounts of particular encounters. The gloss on ਮੂੰਹ ਫੇਰਨਾ describes ordinary usage, not a belief attributed to all Punjabis.
Analysis and forecast. The contrast between an intermediary whose purpose the patient can read and one whose purpose she must guess, the distinction between attention felt and attention shown, the reading of Levinas, the levels of remedy, and the personal standard at the end are the author’s interpretation and preference as of November 6, 2026; they are not a design standard, a legal reading or a measured finding. Independence. This essay is not sponsored by any institution, company, health system or technology developer. It is personal reflection, not medical advice; readers seeking care should contact their own physician’s office.
About the Author #
Kanwar Partap Singh Gill, MD, traces his family roots to Khadur Sahib in Punjab’s Majha region and grew up in Amritsar. He attended Spring Dale School and completed pre-medical studies at Khalsa College in 1994–1996. He earned his MBBS from Sri Guru Ram Das Institute of Medical Sciences and Research in Amritsar in 2002.
He completed PGY-1 at the University of Arkansas for Medical Sciences in Little Rock in 2007–2008, and PGY-2 and PGY-3 with UCSF Fresno at Community Regional Medical Center from 2008 through 2010. He has practiced medicine in California since 2010.
His career has crossed four distinct information eras: predominantly paper-based medicine, early and fragmented electronic records, the integrated-EHR era, and the emerging age of generative and agentic artificial intelligence.