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Doctors are lazy. That’s a brazen, derogatory, declaration that contradicts the usual lofty public image of physicians.
Doctors are lazy. That’s a brazen, derogatory, declaration that contradicts the usual lofty public image of physicians. We are perceived to be hard-working, dedicated and long-suffering individuals who care only about improving and maintaining the health of our patients. But I contend because of anecdotes shared by my patients and from personal experience, doctors seemingly do everything we can to avoid close interaction with the people we are Hippocratically obligated to serve. We simply have gotten complacent about our role and the importance of meaningful interaction with patients and choose to keep people at arm’s length. Sometimes we don’t even see the patient.
During the nearly 40 years I practiced family medicine, not a week went by when a patient didn’t tell me about their experience with other physicians. “You know doc, he wasn’t in the room five minutes.” Or, “he never examined me” What? A physical exam is one of the basic components required for the determination of a diagnosis, and it was omitted?
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I know the physical exam takes time; you might have to wait for the patient to get undressed, or you might have to put on exam gloves. But that exam often provides surprisingly important information you would have otherwise missed. Atrial fibrillation, hepatomegaly, melanoma, DVT, pleural effusion, and murmurs are just a few of the problems easily detected by taking the time to examine the patient. So come on docs, let’s do our job. Examine your patients. They depend on us to do right by them.
Next: 'And then there's the monstrosity called electronic health records'
In today’s world, however, it is not at all uncommon during office hours for the staff to send a patient to the ED who could easily be added to the doctor’s schedule. But because his “schedule is full” or “the office is about to close” the patient is shunted to an unfamiliar facility to see a physician they don’t know and who doesn’t know them. I think this practice undermines the physician-patient relationship and sends a message about the doctor’s dedication to patient care. We need to remember we’re in a service business and take it seriously.
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And then there’s the monstrosity called electronic health records. The EHR concept has a serious purpose and is good for continuity of care, but nothing has driven a wedge between the doctor and patient or reduced physician productivity more than the EHR, and especially the Meaningful Use program.
Because of the complexity of EHRs and the need for thorough documentation, the physician is required to focus more on the computer during the visit than on the patient. Eye contact with patients is like the physical exam; it takes time and gets ignored. You have to look away from the computer. Come on docs. Can’t you make notes as you speak to the patient and do your computer documentation at another time?
Now we have “telemedicine.” In this brilliant process you don’t even see the patient let alone examine them. You talk to them on the phone or have a “video chat.” Doctors are good, but not that good. I cannot recall feeling assured I had made the right diagnosis by speaking to someone on the phone. And, oh, the patient can email you a photo of their rash, but nothing is like seeing it live and “laying on hands.” This is pure insanity and is a perfect setup for a lawsuit. Have we gotten so busy we have to diagnose and treat over the phone? No, we’re just complacent and lazy.
Next: Concept of 'physician extenders'
And finally, we come to the concept of “physician extenders.” Well-trained nurse practitioners and physician assistants provide good, competent care for patients the doctor is unable to see. And they do add to the bottom line financially in this era of bare- bones reimbursement. BUT do they see patients who could be seen by the physician? Has he gotten to the point of complacency that patient care has become an intrusion into other activities?
Nor has the medical profession in general asserted its influence in the matter of policy making. We have allowed insurance company executives and government bureaucrats to make decisions for us and influence the practice of medicine. Private medical practice has become so complex in so many aspects that physicians have sought refuge in the safe, comfortable environment of employment by a hospital or large group.
You simply cannot run a practice without the assistance of multiple employees whom sparse reimbursement will not allow you to afford. Rarely these days do you hear of a young physician “hanging out his shingle.” It’s impossible to know and do and afford all the complex things required to run a practice and get paid for your services.
Next: We have lessened our importance
In my mind, this is not an example of laziness or complacency. It simply what’s happened to the practice of medicine. But we were too lazy and complacent to prevent it from happening. Our “lobbyists” and thought leaders didn’t oppose these changes vigorously enough or provide favorable alternatives to preserve our profession.
We have been lazy in our office practices, work ethic, responsibility to our patients, and ourselves. We have lessened our importance and leadership role to the point we are now called “healthcare providers” or simply “providers” because we are no more important than anyone else in the healthcare hierarchy. I resent that.
So, come on docs. Let’s see, examine, and take responsibility for our patients and work hard on their behalf. The more we dilute our influence or shirk our responsibilities, the less relevant we become. We owe it to our patients, to whom we are ultimately responsible, to stay out in front, be their advocates, and stand up for what is important to them. The practice of medicine and the physician-patient relationship have changed drastically in the last ten years. We cannot be so lazy as to let it get further away from us.
William M. Gilkison, MD
Next: Family docs have MOC concers
Regarding the letter “ABIM is striving for greater transparency” (December 10, 2015): I am not an internist, but until several years ago I was a board-certified family physician. I have joined the debate on MOC because the problems that internists have with the ABIM MOC are similar to those that most family doctors have with the family practice MOC and for that matter the same that pediatricians have with their MOC.
I suspect that the only reason that criticism has been rare among the family doctors and the pediatricians is because generally they are not as aggressive as their colleagues in internal medicine, particularly the specialists who seem to be leading the movement for change.
But the point is that the American Board of Medical Specialties should take a good look at the boards of family medicine and pediatrics as well.
Even more important, after initial certification the responsibility of all the boards should be to promote medical education not to maintain certification. And it should not be done in a punitive manner. The education should be mostly self-assessment.
Physicians are besieged and crushed by numerous regulations that have known no precedent in medical history. Burnout is common and those doctors who can afford to are retiring earlier than they had planned.
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Some have left their practices to join hospital networks. Others have taken administrative roles in private healthcare organizations. Clearly, doctors are feeling the strain and the dogmatic approach of the boards exemplifies how disconnected they are from the realities of everyday practice.
Patients value good doctors who give them time, act in their best interests, and are competent. Board certification doesn’t guarantee any of that. In fact MOC encourages doctors to be “test-takers” and in this way disadvantages them. The entire recertification process is out of sync with doctors’ intellectual, psychological, and practical needs.
If the CEO of the ABIM wants greater transparency he must remove the ignored and unresolved intellectual, psychological and practical difficulties that cloud and distort the MOC process in the first place.
Edward Volpintesta, MD
Next: Insurance execs' salaries inflate healthcare costs
I believe there are more than three reasons for the increased healthcare spending. (“3 ways insurance mergers will affect physician practices,” October 25, 2015). The excessive salaries and bonuses of health insurance CEOs must add greatly to the cost of healthcare insurance. Is any one’s work worth a million dollar salary? Maybe our military in combat.
Also, the insurance companies’ stocks have done well. Profit is good. But when does that profit margin become burdensome to the people requiring it? Apparently the insurance industry does not feel that physicians who actively help mankind (at great liability), are worthy of a “salary” anywhere near an insurance CEO. Instead, we physicians see our pitiful reimbursements trend downward.
James M. Merrill, DO