One of the good things about being an old doctor is that telling the administrators to go to hell is a viable option, because they write it off to microvascular disease.For our younger colleagues it’s more of a problem.
When I was an anesthesiologist, the hospital administration would always claim or doing things just to improve patient care. We all knew was to increase the bottom dollar. They tried to force me as an anesthesiologist into these new protocols for quality purposes, and I would uniformly say not until it’s proven properly by good data . I took a lot of heat, but in the end was proven over and over again to be right.
Anyone who is puzzled by the increasing reliance on complementary, alternative or any of the "woo-woo" care models need only read the above essay. Providers who don't connect with patients on a human level are paving the way for their replacement by AI.
YES!!! I see both sides of this as a nurse, I try to chart as little as I can when I’m with my patient and it frustrates me to no end visiting my PCP -they barely make eye contact and barely touch you, just typing away. Healthcare is in an awful way and has worsened so much even in my short 15 years of practice. I’m not sure how we fix it - no one seems to care!
I agree, NO ONE SEEMS TO CARE!!!! Especially the ones who should. I'm 80 years old and being ignored by my PCP is unacceptable. Makes you feel more like you are expendable! Which is what most physicians seem to think.
As a nurse for 40 years I’m going to have to defend most of the doctors with whom I worked before I retired… believe me, most of them care too much… they are overworked by administrations who are looking at the bottom line (because that is where THEIR bonuses come from!) NOT THE DOCTORS… they rarely get bonuses… just more paperwork and computer programs which they are told will, “make your job SOOO much easier”!! BALONEY! Then, just as they finally find a way to deal with the present program on the computer, TA DA!!! Good news doc!! We have a NEW program for you to learn!! (Hint: no, probably not better, but cheaper… remember… gotta watch out for that bottom line!
If administration paid for scribes for the doctors, it would solve some of those problems… doctors could pay complete attention to their patients and all those quality assurance measures would be met! Only thing as a downside might be a dip in bonuses for the administration… 😜
Years ago when we were pressed to document with the patient, I complained it was rude. I was told “patients are used to it “. It is rude and I still only do the minimum when I’m with them . I am a nurse. I go to the doctor just about never as it’s such an unpleasant experience and almost pointless. The providers change with no notice anymore. They used to send a letter but now I guess it’s so routine that they don’t bother.
And it is NOT because doctors are uncaring, money hungry monsters either! Look to hospital administration and drug company higher ups and insurance companies higher ups… THEY are the ones tanking healthcare!
Patients have a part in this because they want " free " health care. IMO they are getting what they pay for. I am not talking about those who cannot afford out of pocket but too many have money for Disney land but only want to pay a co pay. I had a hip replacement - few could understand why I chose to pay out of pocket to a physician that did not accept Medicare. I had a fabulous experience on every level.
That's total projection. Give me a survey or something. Pure ideology. It depends on the doctor totally and is not connected to willingness or ability to pay.
so well said! If we (patients) wanted to have a machine help us, we'd just check in with Dr. Google or Nurse GPT. Doctors are humans and patients want to see a human who is listening to us, looking us in the eye, seeing our unmasked facial expressions, touching our forehead or whatever hurts etc....It's a full sensory experience to diagnose and treat. Typing up CYA notes is not medicine. Thank you Dr. Prasad for all of your posts, particularly the getting water one.
We've gotten ourselves into a philosophy that every little detail is so important because we keep hear about how healthcare data will be used for some "amazing breakthrough" down the line, but as someone who worked with that data at Cerner for 7 years, it's all garbage. Every little detail you think you're adding while you're sitting there in front of the patient does nothing but feed into the insurance billing systems that overcharge patients for things that should be trivial to afford and continue to push the pharmaceutical company agenda. We continue as a society to believe that the only way to unlock better care is through better data, then we continue to populate the data that some data scientist with no medical background has come to believe is the appropriate data point for "a known algorithm" rather than continuing to trust the medical community who has done decades of research without the data science methodologies of machine learning to progress, finding pathways via the scientific method and hypothesis testing with hands-on labs rather than data farming and data scraping garbage data for loose correlations. As a computer-oriented person, I appreciate when my doctor can pull up my chart and show me my chart and the things in there to help me correlate because I do find myself to be more computationally analytical and those are the things I like to see, but I also believe I'm an oddball when it comes to those abilities and desires, most people want a human touch, want to have a conversation and the human connection. Know your patient, get to know how they click and then you can craft that connection the way your patient wants. After all, being a doctor is very much a patient-service-oriented job despite your schooling not really prioritizing that early on.
It is important to understand that the rise of “evidence based medicine” was a response to the existential anxiety of a generation of clinicians trained to believe that “the literature” or “data” would resolve every issue, and would do so in the moment. The result is overwhelming demand for “evidence” which in many cases either does not exist at all or exists in incomplete or misleading form.
It is quite a task to push someone trained on algorithms towards the exercise of clinical judgement.
After all, if running the algorithm and a few keystrokes for the treatment (plus many keystrokes for the coding) is the essence of the work, PAs are a lot cheaper.
This will be the outcome of the fascination with LLMs
It obscures the “garbage in, garbage out” problem, and along with team-based care has the happy result that no one is to blame.
Being a good doctor is about tailoring the known data and science to meet the needs of the unique individual in front of you of you , and to be able to do this for each and every person.
It’s a dying profession
PAs and AIs is where it’s been heading for a long time
It’s a boom for malpractice lawyers.and for the CEOs of hospitals and other corporations that have sucked the lifeblood out of most doctors.
If it's any consolation, COVID shutdowns and their ensuing years-long court delays decimated the malpractice law industry. Patients have little recourse any more.
I once had a medical student tell me that there was no evidence on how to treat gout “it’s all anecdote.” When I asked her whether she would treat it in the way acceptable in our clinic around 2008, which was analgesics, a short course of steroids and a uric acid inhibitor or excretor, she said “no, my practice will be based on science.” I left that discussion thinking that I’d hate to be one of her patients.
Well said. What's missing is narrative. Data are just fragments. Someone has to tell the story behind them. Medical records were intended to tell the story of the meaningful decision-making interaction between the patient and the care team. Sadly, now there's very little story left to tell.
I had a wonderful teacher for the interview (“history taking”) named Franz Reichsman. He taught me so much that I still use every day. When I was a (snot-nosed) intern we all mocked an attending who was practicing at age 85 and still admitted his patients to the hospital (as all doctors did). He cornered me in the hall one day and, index finger on my chest said “Noble! You think I’m just a stupid little old man! Well, have you noticed that all my patients are little old people, too! Little old people are something you know nothing about, and you had better start paying attention!” Thank you, Dr. Reusch! I hope in the last 50 years I’ve developed to the point that I can live up to your expectations.
Please read this, and if you know, a young doctor share
Being a physician is a privilege
The reward of being a physician is not financial
The reward of being a physician is that patients give you that privilege and you get to be a part of their life in a way that no one else can be.
I learned about what it was like to be going 25 yards a day after landing at Normandy. Another another fellow showed me a watch given to him by LBJ . He said it was the guy in front that did the shooting and that they took the windshield away but that's a story for another day. He was there.
After my serious car accident, there was not a day that did not go by where the majority of the patients did not take time out of their visit to honestly know how I was doing. Same thing when my wife ill
Physicians want to know why they're burned out and why they're unhappy -they're partly to blame .
Put down the damn computer or have the patient look at the computer with you and have them help. You fill it out with them that can help sometimes too as you go through the clicks.
The tragedy is not that the patients are losing out is that the doctors are as well.
The computer was only supposed to be used, and this is a true story , to prevent duplication of labs. Now it's used to create fake notes that result in more pay and are totally unreliable. How many women have normal prostates and how many men have normal pelvics? Reading some of the notes more than you would think.
As the doctors click away, thinking they're doing a great job they are losing out on the privilege of being a physician and so are the patients, we all lose
Older doctors are either retired or almost retired. Dr Prasad’s generation still had good role models, and remember handwritten SOAP notes..The younger doctors have no way to know any better.. They speak a completely different language and have very different expectations, and were and fewer Excellent doctors to emulate.
It was planned this way decades ago when hospital systems started buying out independent practices. Doctors sold out the profession
There was no choice for cardiology . CMS cut cardiology 20% in one year and groups would have disintegrated . We actually went to DC and met with CMS and told them this would happen. I personally spoke to them and said they were going to see a dramatic increase in hosp billing done by hospitals. Then they had the nerve to come to a cardiology meeting and claim that we were in cahoots with the hospital and it cost $2 billion. I actually stood up in front of 400 cardiologist and said you cannot rewrite history. We told you this would happen and you said you didn't care because it was Medicare B money and you were only focused on Medicare A. You didn't change the fee schedule and now we are all employees so don't talk to us anymore talk to our bosses.
What year was this? I have a lot of first hand knowledge and experience about how this transpired. What is clear to me now is it was done purposefully to take control of medicine away from Doctors and hand it over to corporations and other MBAs .
I still think If the wealthier, most senior Doctors had not caved , things would be very different. I would really like to hear more about your experience ( when and what part of the country etc) I will message you . Thank you for engaging
We just had a big discussion about this with friends after I shared your “drink of water” post! Several people talked about doctors who never even looked up from their note taking.
Thank you for this. I remember the written notes. Miss those days. It’s all too much useless clicking and documentation for the insurance companies to keep tabs on stats. Medicine needs an overhaul.
Patients are no longer seen as people or individuals.
I have just moved house and had to go and see a new doctor. No history taken whatsoever, no physical examination, no lab tests, then she diagnosed me based on her preconceptions of someone my age/sex.
I was taught to diagnose far better in the Army Reserve!
Needless to say, I went to a different doctor the next time.
I had a very similar experience w a new MD after I moved, but since the age of 59, most MD's assessments start off with, "welcome to old age." No one would know how physically active I am because no one asks. The time she took for her lengthy lecture re screenings could have been put to better use.
If you’ve been to a doctor in recent years, you have experienced this.
I traveled 3 hours to take my 88 yo mother to a neurosurgeon to see if her brain bleed had resolved. He typed the first 10 mins using a voice to text feature. Every time he talked we jumped out of our skin because we didn’t know if he was talking to us or not. I figured out he was talking into a headset (think call center) but my concussed mother never did & became more confused. After 10 mins of this he turned to my mom and said your brain bleed resolved. Talk about burying the lede. To be fair, he spent the next 5 minutes talking to us with eye contact.
The whole system needs to be revised but I don’t see that happening anytime soon.
I was in sales and learned to set client expectations early. Maybe if the doctor had said something like:
1. Mrs. X , good news, your brain bleed resolved on its own. No need for surgery.
2. Now, I need to use my headset to talk to the computer to enter some important data into your record. It will take about x minutes. Then I want to hear all about how you are doing. I appreciate you giving me the opportunity to care for you.
3. Talk to patient & perform exam.
I’m just spitballing and there’s probably a better recipe of steps , but setting expectations helps to relieve the frustration of the unknown/lack of control people feel when ignored. It will not solve the dr/patient communication problem totally but maybe it is a tiny step in the right direction if we have to work within the current system.
Uncommunicated expectations are a down payment on disappointment.
As for me, I stopped going to the doctor altogether. For many reasons.
Anyone who is puzzled by the increasing reliance on complementary, alternative or any of the "woo-woo" care models need only read the above essay. Providers who don't connect with patients on a human level are paving the way for their replacement by AI.
During the 41 years I spent in private practice as a family physician, my biggest headache and frustration was that there was never enough of me to meet all of the expectations. In trying to fulfill the Medicare/insurance guidelines, HEDIS measures, maintaining Press Ganey scores, EMR maintenance to corporate standards, keeping my in box cleared, achieving patient volumes to make a reasonable income, having time with my wife and family, offering quality time with my patients worthy of the trust they gave me, my quality of life was nil and my satisfaction less. I realized that I was the bottleneck. I had to check everything, order everything, give instructions for everything, and sign everything. There was too little of me. I either had to improve the process by seeing less patients or impact the quality of care by having to cut corners, neither one an acceptable situation. Improving scheduling, streamlining EMR processes, limiting patient access to me did little to improve the situation. I was on the verge of burn out.
Then I came upon a wonderful concept, a different patient care model…the team-care model. This has been around for a while but is way under utilized. The concept is to share the work load by delegating all the responsibilities, except those that absolutely required my attention and authorization, to those who work with me, allowing those individuals to work to the maximum of their licensure. Instead of a 1:1 ratio for physicians to MA/nurses, it should be at least 1:2.5. With appropriate additional training, it is possible to have a MA or nurse obtain all the HPI, update PMH, SH, FH, and reconcile medication before I entered the room, then give me a summary or report of the patient information in the patient’s presence. As I asked any additional questions, did my physical exam while verbally reporting my findings, discussed my assessment with the patient, along with explaining my plans, the assistant entered this information and orders into the EMR. I then had time to answer any additional questions for the patient and sign off the record. In the meantime, the other assistant was preparing the next patient in the same way. The 0.5 assistant (shared with my partners) answered messages, called in medications, made me aware of urgent matters, etc.
My face to face time was shortened by >50% because I did not have to obtain and enter the information into the record. Yet the patient knew what information I was given, felt they had been listened to, had a clear understanding of what I thought their issues were and what we were going to do about them. Patient satisfaction increased greatly, improving Press Ganey scores. The accuracy of the EMR information was increased and more complete. Billing for the visit could be increased due to improved documentation. My patient volume increased significantly as did my quality of care. My staff felt more involved in impacting patients’ health, improving their satisfaction and decreasing staff turnover. Administration was happy because of increased productivity, decreased staff turnover, increased patient satisfaction, improved quality measures, etc. My quality of life improved greatly, bringing back the joy of practicing medicine. My only regret was that I found this innovative way of practicing so late in my career.
I have been reading these comments and was happy to come across this one. As a family physician who practiced for 20 years and now is mostly in administration I agree with the challenges of the medical industrial complex covered in Dr. Wagner’s review of all the competing measures that primary care doctors are required to complete, documentation being only one of the administrative measurements. How we got here is a long and complex journey which includes but isn’t limited to the EMR. The EMR implementation rush was pushed for in healthcare policy, and sold to healthcare organizations with a promise of better reimbursement either through the carrot and stick approach to adoption (meaningful use) or by the EMR companies to enhance billing. Those forces somehow dictated the build of a frustrating system for documenting patient care that absorbs too much of a physician, APP or nurses time and robs them of the joy of medicine. This is where doctors, APPs and nurses need a voice, these practice changing decisions that we are left dealing with for decades, with ongoing improvements needed just to support a more reasonable work - life balance. I admit, I don’t know how to ensure that healthcare policy leads to better healthcare for patients and providers of care alike, or how to get practicing clinicians involved. We probably need much stronger lobbyists in DC to compete with the deep pockets of big pharma and insurers. That proabably means we need to contribute more to our medical societies, and be more politically active. I know we want to work in a better system, but the system starts with policy, and funding models. I also want to share my hope that AI scribing could be a solution, and I think it is one we need to embrace for our patients, our families and our personal wellness. If you have the option of using an AI scribe as an assistant and charting is getting in the way with your care of the patient and or your work life balance I would encourage you to take that option and work with it until charting isn’t the thing that is getting in the way. Finally, working with primary care physicians and APPs I know that they care deeply right up until they can’t care as much mostly out of self preservation that is burnout. It isn’t a bad doctor it is a system that forces a resilient, intelligent, caring professional to make personal sacrifices until they can’t. Certainly we can get in our own way, and I have had that talk with myself about what is really important here, and I have had to make trade offs to be able to care for patients, do I need to document every word? Of course not! Do I need to repeat myself for the patient to understand? Of course not, I could ask them simply what they understand. Do I need to do everything for everyone at every visit? Of course not, it is unrealistic and adds to my sense of victimization. At the end of the day I am the one in control of the patient encounter, and what matters is good medicine that is personalized because I know that patient over many visits. So I am working to bring team based care to my organization, along with many other leaders, who could also be branded with the term administrator. We work in healthcare in our organization for the same reason that clinicians do, because we care about patients, and we care about our teams.
Great insights and important points were brought forward. From a bird’s eye perspective, physicians are still in charge. Until they place their signature on the order, note, form, prescription, etc., nothing happens, the system comes to a halt. We, physicians, need to continue to be innovative to find, and insist on, the tools, EMR systems, assistants, care models, and anything else that will get us to the goal of healthcare excellence, while maintaining a work/life balance. Physicians are still among the smartest and most gifted people of any profession. They are the only ones truly qualified to lead the charge.
Thank you for this! I've been treated by providers who barely looked at me. They asked questions while staring at a screen and typed as I answered. It's dehumanizing.
One of the good things about being an old doctor is that telling the administrators to go to hell is a viable option, because they write it off to microvascular disease.For our younger colleagues it’s more of a problem.
When I was an anesthesiologist, the hospital administration would always claim or doing things just to improve patient care. We all knew was to increase the bottom dollar. They tried to force me as an anesthesiologist into these new protocols for quality purposes, and I would uniformly say not until it’s proven properly by good data . I took a lot of heat, but in the end was proven over and over again to be right.
Anyone who is puzzled by the increasing reliance on complementary, alternative or any of the "woo-woo" care models need only read the above essay. Providers who don't connect with patients on a human level are paving the way for their replacement by AI.
YES!!! I see both sides of this as a nurse, I try to chart as little as I can when I’m with my patient and it frustrates me to no end visiting my PCP -they barely make eye contact and barely touch you, just typing away. Healthcare is in an awful way and has worsened so much even in my short 15 years of practice. I’m not sure how we fix it - no one seems to care!
I agree, NO ONE SEEMS TO CARE!!!! Especially the ones who should. I'm 80 years old and being ignored by my PCP is unacceptable. Makes you feel more like you are expendable! Which is what most physicians seem to think.
As a nurse for 40 years I’m going to have to defend most of the doctors with whom I worked before I retired… believe me, most of them care too much… they are overworked by administrations who are looking at the bottom line (because that is where THEIR bonuses come from!) NOT THE DOCTORS… they rarely get bonuses… just more paperwork and computer programs which they are told will, “make your job SOOO much easier”!! BALONEY! Then, just as they finally find a way to deal with the present program on the computer, TA DA!!! Good news doc!! We have a NEW program for you to learn!! (Hint: no, probably not better, but cheaper… remember… gotta watch out for that bottom line!
If administration paid for scribes for the doctors, it would solve some of those problems… doctors could pay complete attention to their patients and all those quality assurance measures would be met! Only thing as a downside might be a dip in bonuses for the administration… 😜
I don’t want a scribe in the room with my primary care. Don’t mind with my Dermatologist. Also don’t like automated scribes so decline.
That's why the jab was created.
To depopulate the planet
Years ago when we were pressed to document with the patient, I complained it was rude. I was told “patients are used to it “. It is rude and I still only do the minimum when I’m with them . I am a nurse. I go to the doctor just about never as it’s such an unpleasant experience and almost pointless. The providers change with no notice anymore. They used to send a letter but now I guess it’s so routine that they don’t bother.
Healthcare continues to worsen. It has become an assembly line and patients are valued as profits instead of people.
And it is NOT because doctors are uncaring, money hungry monsters either! Look to hospital administration and drug company higher ups and insurance companies higher ups… THEY are the ones tanking healthcare!
They are saying that the patients are used to people being rude to them! It's a sad state of affairs
Patients have a part in this because they want " free " health care. IMO they are getting what they pay for. I am not talking about those who cannot afford out of pocket but too many have money for Disney land but only want to pay a co pay. I had a hip replacement - few could understand why I chose to pay out of pocket to a physician that did not accept Medicare. I had a fabulous experience on every level.
A hip replacement Dr. that does not accept Medicare?
That’s just not right for the senior patient nor for the physician’s pocketbook
That's total projection. Give me a survey or something. Pure ideology. It depends on the doctor totally and is not connected to willingness or ability to pay.
Physicians became fungible when they accepted being providers not physicians.
so well said! If we (patients) wanted to have a machine help us, we'd just check in with Dr. Google or Nurse GPT. Doctors are humans and patients want to see a human who is listening to us, looking us in the eye, seeing our unmasked facial expressions, touching our forehead or whatever hurts etc....It's a full sensory experience to diagnose and treat. Typing up CYA notes is not medicine. Thank you Dr. Prasad for all of your posts, particularly the getting water one.
CYA NOTES is EXACTLY what's happening. Well said, and It's no longer medicine.
You think this is bad, just look at the UK and the paperwork requirements of the NHS. Dr. Malcolm Kendrick has some very passionate posts about this.
Way worse on UK and Canada
Because they are fully Socialized Medicine - we are only on our way to that fate - unless we stop it. Fight for it !
Does Dr Kendrick have a sub? Reading his ‘The Clot Thickens’ book rn
No substack, but a blog at https://drmalcolmkendrick.org. It's WordPress so commenting is kind of a pain, but the blog is excellent.
Thx!
We've gotten ourselves into a philosophy that every little detail is so important because we keep hear about how healthcare data will be used for some "amazing breakthrough" down the line, but as someone who worked with that data at Cerner for 7 years, it's all garbage. Every little detail you think you're adding while you're sitting there in front of the patient does nothing but feed into the insurance billing systems that overcharge patients for things that should be trivial to afford and continue to push the pharmaceutical company agenda. We continue as a society to believe that the only way to unlock better care is through better data, then we continue to populate the data that some data scientist with no medical background has come to believe is the appropriate data point for "a known algorithm" rather than continuing to trust the medical community who has done decades of research without the data science methodologies of machine learning to progress, finding pathways via the scientific method and hypothesis testing with hands-on labs rather than data farming and data scraping garbage data for loose correlations. As a computer-oriented person, I appreciate when my doctor can pull up my chart and show me my chart and the things in there to help me correlate because I do find myself to be more computationally analytical and those are the things I like to see, but I also believe I'm an oddball when it comes to those abilities and desires, most people want a human touch, want to have a conversation and the human connection. Know your patient, get to know how they click and then you can craft that connection the way your patient wants. After all, being a doctor is very much a patient-service-oriented job despite your schooling not really prioritizing that early on.
It is important to understand that the rise of “evidence based medicine” was a response to the existential anxiety of a generation of clinicians trained to believe that “the literature” or “data” would resolve every issue, and would do so in the moment. The result is overwhelming demand for “evidence” which in many cases either does not exist at all or exists in incomplete or misleading form.
It is quite a task to push someone trained on algorithms towards the exercise of clinical judgement.
After all, if running the algorithm and a few keystrokes for the treatment (plus many keystrokes for the coding) is the essence of the work, PAs are a lot cheaper.
This will be the outcome of the fascination with LLMs
It obscures the “garbage in, garbage out” problem, and along with team-based care has the happy result that no one is to blame.
Being a good doctor is about tailoring the known data and science to meet the needs of the unique individual in front of you of you , and to be able to do this for each and every person.
It’s a dying profession
PAs and AIs is where it’s been heading for a long time
It’s a boom for malpractice lawyers.and for the CEOs of hospitals and other corporations that have sucked the lifeblood out of most doctors.
If it's any consolation, COVID shutdowns and their ensuing years-long court delays decimated the malpractice law industry. Patients have little recourse any more.
When 'Evidence-Based Medicine' discounts actual patient experience I change doctors. At my age I just don't have time left for that bullshit!
I once had a medical student tell me that there was no evidence on how to treat gout “it’s all anecdote.” When I asked her whether she would treat it in the way acceptable in our clinic around 2008, which was analgesics, a short course of steroids and a uric acid inhibitor or excretor, she said “no, my practice will be based on science.” I left that discussion thinking that I’d hate to be one of her patients.
Your last sentence especially.
Well said. What's missing is narrative. Data are just fragments. Someone has to tell the story behind them. Medical records were intended to tell the story of the meaningful decision-making interaction between the patient and the care team. Sadly, now there's very little story left to tell.
I had a wonderful teacher for the interview (“history taking”) named Franz Reichsman. He taught me so much that I still use every day. When I was a (snot-nosed) intern we all mocked an attending who was practicing at age 85 and still admitted his patients to the hospital (as all doctors did). He cornered me in the hall one day and, index finger on my chest said “Noble! You think I’m just a stupid little old man! Well, have you noticed that all my patients are little old people, too! Little old people are something you know nothing about, and you had better start paying attention!” Thank you, Dr. Reusch! I hope in the last 50 years I’ve developed to the point that I can live up to your expectations.
Please read this, and if you know, a young doctor share
Being a physician is a privilege
The reward of being a physician is not financial
The reward of being a physician is that patients give you that privilege and you get to be a part of their life in a way that no one else can be.
I learned about what it was like to be going 25 yards a day after landing at Normandy. Another another fellow showed me a watch given to him by LBJ . He said it was the guy in front that did the shooting and that they took the windshield away but that's a story for another day. He was there.
After my serious car accident, there was not a day that did not go by where the majority of the patients did not take time out of their visit to honestly know how I was doing. Same thing when my wife ill
Physicians want to know why they're burned out and why they're unhappy -they're partly to blame .
Put down the damn computer or have the patient look at the computer with you and have them help. You fill it out with them that can help sometimes too as you go through the clicks.
The tragedy is not that the patients are losing out is that the doctors are as well.
The computer was only supposed to be used, and this is a true story , to prevent duplication of labs. Now it's used to create fake notes that result in more pay and are totally unreliable. How many women have normal prostates and how many men have normal pelvics? Reading some of the notes more than you would think.
As the doctors click away, thinking they're doing a great job they are losing out on the privilege of being a physician and so are the patients, we all lose
Re patients helping doctors fill out the record, so often the patient has submitted online forms, which never seem to make it into the record.
Yes. I always submit the online forms ahead of time, and then am asked the same questions during the visit.
My answer: It's on MyChart, DO NOT COME TO ME UNPREPARED!
It's supposed to go to whatever EHR they're using and then to MyChart. By the time I arrive at a new patient visit, it should be there.
I tell new docs/nurses/ pa's 'Read-Understand and follow what has been written, it will save us both time and needless explanations.
Fired my last PCP because he wrote about my need for (among other things) ASPIRIN...which was noted as giving me GI bleeds.
Older doctors are either retired or almost retired. Dr Prasad’s generation still had good role models, and remember handwritten SOAP notes..The younger doctors have no way to know any better.. They speak a completely different language and have very different expectations, and were and fewer Excellent doctors to emulate.
It was planned this way decades ago when hospital systems started buying out independent practices. Doctors sold out the profession
There was no choice for cardiology . CMS cut cardiology 20% in one year and groups would have disintegrated . We actually went to DC and met with CMS and told them this would happen. I personally spoke to them and said they were going to see a dramatic increase in hosp billing done by hospitals. Then they had the nerve to come to a cardiology meeting and claim that we were in cahoots with the hospital and it cost $2 billion. I actually stood up in front of 400 cardiologist and said you cannot rewrite history. We told you this would happen and you said you didn't care because it was Medicare B money and you were only focused on Medicare A. You didn't change the fee schedule and now we are all employees so don't talk to us anymore talk to our bosses.
What year was this? I have a lot of first hand knowledge and experience about how this transpired. What is clear to me now is it was done purposefully to take control of medicine away from Doctors and hand it over to corporations and other MBAs .
I still think If the wealthier, most senior Doctors had not caved , things would be very different. I would really like to hear more about your experience ( when and what part of the country etc) I will message you . Thank you for engaging
2009 -went into effect 2010.ACC sued CMS and lost
Indeed they did.
We just had a big discussion about this with friends after I shared your “drink of water” post! Several people talked about doctors who never even looked up from their note taking.
Thank you for this. I remember the written notes. Miss those days. It’s all too much useless clicking and documentation for the insurance companies to keep tabs on stats. Medicine needs an overhaul.
Patients are no longer seen as people or individuals.
I have just moved house and had to go and see a new doctor. No history taken whatsoever, no physical examination, no lab tests, then she diagnosed me based on her preconceptions of someone my age/sex.
I was taught to diagnose far better in the Army Reserve!
Needless to say, I went to a different doctor the next time.
I had a very similar experience w a new MD after I moved, but since the age of 59, most MD's assessments start off with, "welcome to old age." No one would know how physically active I am because no one asks. The time she took for her lengthy lecture re screenings could have been put to better use.
If you’ve been to a doctor in recent years, you have experienced this.
I traveled 3 hours to take my 88 yo mother to a neurosurgeon to see if her brain bleed had resolved. He typed the first 10 mins using a voice to text feature. Every time he talked we jumped out of our skin because we didn’t know if he was talking to us or not. I figured out he was talking into a headset (think call center) but my concussed mother never did & became more confused. After 10 mins of this he turned to my mom and said your brain bleed resolved. Talk about burying the lede. To be fair, he spent the next 5 minutes talking to us with eye contact.
The whole system needs to be revised but I don’t see that happening anytime soon.
I was in sales and learned to set client expectations early. Maybe if the doctor had said something like:
1. Mrs. X , good news, your brain bleed resolved on its own. No need for surgery.
2. Now, I need to use my headset to talk to the computer to enter some important data into your record. It will take about x minutes. Then I want to hear all about how you are doing. I appreciate you giving me the opportunity to care for you.
3. Talk to patient & perform exam.
I’m just spitballing and there’s probably a better recipe of steps , but setting expectations helps to relieve the frustration of the unknown/lack of control people feel when ignored. It will not solve the dr/patient communication problem totally but maybe it is a tiny step in the right direction if we have to work within the current system.
Uncommunicated expectations are a down payment on disappointment.
As for me, I stopped going to the doctor altogether. For many reasons.
Thank you Dr. Prasad.
Anyone who is puzzled by the increasing reliance on complementary, alternative or any of the "woo-woo" care models need only read the above essay. Providers who don't connect with patients on a human level are paving the way for their replacement by AI.
During the 41 years I spent in private practice as a family physician, my biggest headache and frustration was that there was never enough of me to meet all of the expectations. In trying to fulfill the Medicare/insurance guidelines, HEDIS measures, maintaining Press Ganey scores, EMR maintenance to corporate standards, keeping my in box cleared, achieving patient volumes to make a reasonable income, having time with my wife and family, offering quality time with my patients worthy of the trust they gave me, my quality of life was nil and my satisfaction less. I realized that I was the bottleneck. I had to check everything, order everything, give instructions for everything, and sign everything. There was too little of me. I either had to improve the process by seeing less patients or impact the quality of care by having to cut corners, neither one an acceptable situation. Improving scheduling, streamlining EMR processes, limiting patient access to me did little to improve the situation. I was on the verge of burn out.
Then I came upon a wonderful concept, a different patient care model…the team-care model. This has been around for a while but is way under utilized. The concept is to share the work load by delegating all the responsibilities, except those that absolutely required my attention and authorization, to those who work with me, allowing those individuals to work to the maximum of their licensure. Instead of a 1:1 ratio for physicians to MA/nurses, it should be at least 1:2.5. With appropriate additional training, it is possible to have a MA or nurse obtain all the HPI, update PMH, SH, FH, and reconcile medication before I entered the room, then give me a summary or report of the patient information in the patient’s presence. As I asked any additional questions, did my physical exam while verbally reporting my findings, discussed my assessment with the patient, along with explaining my plans, the assistant entered this information and orders into the EMR. I then had time to answer any additional questions for the patient and sign off the record. In the meantime, the other assistant was preparing the next patient in the same way. The 0.5 assistant (shared with my partners) answered messages, called in medications, made me aware of urgent matters, etc.
My face to face time was shortened by >50% because I did not have to obtain and enter the information into the record. Yet the patient knew what information I was given, felt they had been listened to, had a clear understanding of what I thought their issues were and what we were going to do about them. Patient satisfaction increased greatly, improving Press Ganey scores. The accuracy of the EMR information was increased and more complete. Billing for the visit could be increased due to improved documentation. My patient volume increased significantly as did my quality of care. My staff felt more involved in impacting patients’ health, improving their satisfaction and decreasing staff turnover. Administration was happy because of increased productivity, decreased staff turnover, increased patient satisfaction, improved quality measures, etc. My quality of life improved greatly, bringing back the joy of practicing medicine. My only regret was that I found this innovative way of practicing so late in my career.
I have been reading these comments and was happy to come across this one. As a family physician who practiced for 20 years and now is mostly in administration I agree with the challenges of the medical industrial complex covered in Dr. Wagner’s review of all the competing measures that primary care doctors are required to complete, documentation being only one of the administrative measurements. How we got here is a long and complex journey which includes but isn’t limited to the EMR. The EMR implementation rush was pushed for in healthcare policy, and sold to healthcare organizations with a promise of better reimbursement either through the carrot and stick approach to adoption (meaningful use) or by the EMR companies to enhance billing. Those forces somehow dictated the build of a frustrating system for documenting patient care that absorbs too much of a physician, APP or nurses time and robs them of the joy of medicine. This is where doctors, APPs and nurses need a voice, these practice changing decisions that we are left dealing with for decades, with ongoing improvements needed just to support a more reasonable work - life balance. I admit, I don’t know how to ensure that healthcare policy leads to better healthcare for patients and providers of care alike, or how to get practicing clinicians involved. We probably need much stronger lobbyists in DC to compete with the deep pockets of big pharma and insurers. That proabably means we need to contribute more to our medical societies, and be more politically active. I know we want to work in a better system, but the system starts with policy, and funding models. I also want to share my hope that AI scribing could be a solution, and I think it is one we need to embrace for our patients, our families and our personal wellness. If you have the option of using an AI scribe as an assistant and charting is getting in the way with your care of the patient and or your work life balance I would encourage you to take that option and work with it until charting isn’t the thing that is getting in the way. Finally, working with primary care physicians and APPs I know that they care deeply right up until they can’t care as much mostly out of self preservation that is burnout. It isn’t a bad doctor it is a system that forces a resilient, intelligent, caring professional to make personal sacrifices until they can’t. Certainly we can get in our own way, and I have had that talk with myself about what is really important here, and I have had to make trade offs to be able to care for patients, do I need to document every word? Of course not! Do I need to repeat myself for the patient to understand? Of course not, I could ask them simply what they understand. Do I need to do everything for everyone at every visit? Of course not, it is unrealistic and adds to my sense of victimization. At the end of the day I am the one in control of the patient encounter, and what matters is good medicine that is personalized because I know that patient over many visits. So I am working to bring team based care to my organization, along with many other leaders, who could also be branded with the term administrator. We work in healthcare in our organization for the same reason that clinicians do, because we care about patients, and we care about our teams.
Great insights and important points were brought forward. From a bird’s eye perspective, physicians are still in charge. Until they place their signature on the order, note, form, prescription, etc., nothing happens, the system comes to a halt. We, physicians, need to continue to be innovative to find, and insist on, the tools, EMR systems, assistants, care models, and anything else that will get us to the goal of healthcare excellence, while maintaining a work/life balance. Physicians are still among the smartest and most gifted people of any profession. They are the only ones truly qualified to lead the charge.
If the doctor does not examine my body - I never go back!
They never do anymore!! Just order tests…
And prescribe statins - another reason NEVER to go back
I stopped visiting the doctor when they stopped being present in the exam room. Clearly I was being managed by software, not treated by a doctor.
Thank you for this! I've been treated by providers who barely looked at me. They asked questions while staring at a screen and typed as I answered. It's dehumanizing.
I call them out on it.
Am their least favorite patient