There are many reasons I left traditional medicine. For more than four decades I cared for patients in my office and then, when necessary, followed them to the emergency room or the hospital. I have jokingly told patients I could take out their appendix, but they would probably never be quite the same again. The Apostle Paul observed that we all have “gifts differing” and operations should be done by experienced surgeons, not internists. Nonetheless, I managed hospital patients with pneumonia, heart failure, stroke, cancer and even issues of palliative care.
Unfortunately, all but one of the internists I shared medical call with, left hospital practice, and at sixty-three years old I was faced with the prospect of every other night and every other weekend on call. When I began medical practice forty years ago, I shared every third night medical call with two other internists and we went to three hospitals to care for patients. I’ve had patients needing my attention simultaneously in three emergency rooms. But I was younger then, and with the world changing I surrendered to modernity. Now, hospitalists (strangers) take care of my patients when hospitalized.
A recent story in the New York Post (January 16, 2019) is making the rounds and caught my eye. Entitled, Alarming burnout is making doctors want to kill themselves. If you’re concerned that your doctor is among the 44% who are so stressed out that they are considering leaving medicine, perhaps you should read the article which reports the annual WebMD/Medscape survey. The principle issue is “paperwork.” Actually, it is paperless Electronic Medical Record (EMR) keeping. I understand what these frustrated doctors are reporting because I made the quantum leap to EMR before my retirement from traditional practice. It was tough, but I did it. Unfortunately, according to my colleagues still in the system, data entry requirements have risen exponentially since I left traditional medicine five years ago.
Late in my medical career, patients would occasionally come to me from well respected doctors in the community. When I inquired why they decided to change doctors I was told, “He never looked at me, just typed on the computer.” Another said, “He never touched me.” Of course these are anecdotal reports, but in the WebMD survey one third of doctors report they get exasperated with their patients. And “14% say they make errors they wouldn’t normally make” as they “point and click” on the computer screen for EMR data entry. The survey is especially alarming in that one in seven doctors have contemplated suicide. Fifty percent of urologists and neurologists report burnout. The happiest group of doctors? Plastic surgeons. They didn’t survey concierge medical doctors like me. I’m off the grid, out of EMR and happy caring for my patients.
A noted cardiologist in Knoxville once sent me a letter detailing the salient points in a patient’s care but apologized for the fluff in the accompanying voluminous EMR notes. He wrote the letter stating his concern that the fluff might obscure the important points. Recently, one of my patients fell and broke her leg while vacationing in Florida. She had a tough time with surgery and bleeding and even had to be readmitted to the hospital from a rehab center after a seizure. She finally made it back to Knoxville, and “that’s when the fight began.”
As her internist, I needed the operation note and the two summaries of her hospitalizations – perhaps a total of six pages. I spoke with two of the doctors caring for her in Florida explaining what I needed and why. In 1996 The Health Insurance Portability and Accountability Act (HIPAA) was passed by Congress to protect patient confidentiality, but also to facilitate the exchange of relevant medical information between doctors. The Florida doctors referred me to the hospital medical records department and then the rehab center did the same. Finally my request was referred to a medical records company in Pueblo, Colorado. I’ve yet to receive the appropriate records because bureaucracy and bureaucrats now control much of medical care. I haven’t given up, but you should ask yourself if your doctor has the time or impetus to doggedly fight for your records and sift through them for the relevant data amidst the fluff.
These days much of my practice is through my iPhone. My patients and I communicate by phone, email, Skype, text and I make house calls. There are no intermediaries. My patients see only me, except when hospitalized. However, even then I visit them just like their minister hopefully does.
I’ve gone back to paper charts which can’t be hacked. I no longer need a fax machine – still used everywhere – because I use an app on my iPhone called eFax. I have access to an excellent medical library on my smartphone with UpToDate, a constantly updated compendium of medical knowledge. I spend lots of time with my patients because I’m not limited to the twelve to fifteen minute visit. And Big Brother doesn’t review my notes which are nonetheless complete, yet succinct. When I was kid, my general practitioner kept my records on 4X6 note cards. I chose internal medicine as a pragmatic discipline between general practice and subspecialty care such as cardiology. The records I dictate on my iPhone and then print are certainly more complete than note cards, but have far less fluff than a six to seven page EMR note generated to maximize charges.
EMR was supposed to help doctors and patients. But, like the lines, “you can keep your doctor” and “your health coverage is going to cost $2500 less a year,” it is another fabulously expensive government mandated boondoggle. Recently, I read on the Internet – so it must be true – that 20 years ago there were three support staff for every physician. Now, there are sixteen support persons per doctor. ER doctors now have scribes who accompany them and take notes to complete the EMR note. This improves a doctor’s efficiency and increases billable charges. And we wonder why medical care costs are going up.
Aristotle once said, “This younger generation has no respect for its elders, and is going to the dogs.” Perhaps it’s been going that direction for 2400 years. Or was the sage envisioning Beto O’Rourke and Alexandria Ocasio-Cortez?