A Stranger in Your Exam Room

It is often difficult for patients to discuss personal issues with their doctors. Thanks to electronic records, it just got a whole lot harder.

Electronic Medical records have been a major disappointment. In survey after survey doctors tell stories of unmet promises and unexpected failures. While electronic prescribing, data collection and legibility of records are a positive, patients tell of doctors never looking up from the computer screen and of more time waiting and less time with the doctor. Doctors feel detached from patients, are stressed when they fall behind, and wonder when the promise of easily accessed data from other doctors will ever be realized. Some of these difficulties are understandable but there is one negative aspect of electronic records that is particularly troubling to patients, especially those dealing with intensely personal issues such as mental health and family conflicts. Many doctors are hiring “scribes”, people whose job it is to enter data into the computerized record on behalf of the doctor.

For some physician’s this is a matter of survival. Inefficient medical software and limited computer and typing skills have resulted in plummeting physician productivity. Declining reimbursements and rising costs make it impossible for doctors to cut back on volume to allow them to enter data themselves. They see no choice but to hire someone to do the work for them. When paying someone $25 an hour to enter data allows you to see an additional 6 patients a day, the math is easy. Spending $200 to make $600 is a return on investment that cannot be ignored.

While physicians are comfortable with an extra person in the exam room during the interview, patients are not always in agreement. Privacy laws and confidentiality policies do not change the fact that this extra person may learn things about a patient's marriage, sex life, depression or drug use that the patient wishes they hadn't. There is a real risk that as a result some patients may withhold information crucial to their care.

So what can be done? At the moment options are limited. Patients have a right to ask that a scribe not be present, but this may strain the relationship with the physician as it is essentially asking the doctor to fall behind in the office.

Some physicians have addressed the problem by charging extra fees to patients to cover the costs of longer visits. I have seen physicians charge from $900 to $3000 dollars a year per patient to be a part of a practice that schedules fewer visits per day, giving more face to face time with the doctor. Unfortunately these membership fees are not covered by insurance and out of the reach of many families. Doctors who participate in HMO plans are contractually banned from charging such fees.

As with many medical conditions, there is no readily available treatment or cure. For the moment, doctors and patients will need to learn to live with the pain and hope things get better over time. I am not sure they will.

-          Bart

Comments and questions are always welcome. Remember to subscribe to the blog to have posts delivered to your inbox. I can also be followed on twitter @bartbarrettmd. 

 

The Loneliness that Cancer Brings

Two young children and a husband with cancer. It was impossible not to worry. She tried to be positive and supportive, but the fears were inescapable. What if the cancer spread? How many years did they have left? If her worst fears materialized, how would she make it?

Her husband either did not share or fears or did a much better job of suppressing them. Like so many cancer patients I have seen he decided that talking and worrying didn’t change anything, so he focused on getting back to work and a sense of normalcy. He kept the details of his Illness a secret to his friends and his extended family, preferring to avoid the questions and the scrutiny.

While this modified form of denial seemed to work well for him it was difficult for her. Unable to share the secret she often felt alone in her grief and worry. She longed to be able to tell others, shed tears, and receive hugs and prayers.

Theirs is not an uncommon tale. A cancer diagnosis is typically more difficult for family members than it is for the patient. The patient focuses on treatments and recovery, the family just worries.

The stress of family members illustrates another common aspect of our society, isolation and lack of community. Deep friendships and meaningful relationships are increasingly rare. People focus on work and family with little time for anything else. Acquaintances are made with other parents through youth sports and activities but there is little opportunity for serious conversations at soccer games and pizza parties. When difficult times come people often have no where to turn.

Years ago I heard a pastor bring this point home by asking the question, “If your husband or wife was in the ICU facing death, who would you want sitting by your side?” Most people struggled to come up with more than a handful of names.

The pastor’s question and the young mother’s struggles serve as a powerful reminder of how important it is to develop friendships and invest in the lives of others. We never know when we may need encouragement and support or when others may need us.

- Bart

Comments and questions are welcomed. You can subscribe to the blog by clicking the button on the page, or you can be notified of posts via twitter @bartbarrettmd. You can share posts with others by clicking one of the share icons that follow the post, it is the only way others learn of the blog

10 Things Patients Want From their Doctors

Unhappy with the service you receive from your doctor? Want to tell them how they can do a better job? Here is a list of things patients all deserve from their doctors, feel free to share it with your physician.

Patients deserve-

1-      A smile. They deserve one from the receptionist and from the doctor. They are the reason we all have a job!

2-      A doctor who is on time. Patients understand that we have emergencies but also know that we do not have emergencies every day. Repeated long waits tell patients that we are uncaring and disorganized. My personal solution to the problem is to schedule same day illness appointments at the end of the morning after I am done with scheduled patients. My scheduled patients then have the time they need.

3-      A meaningful apology. When I am behind more than 30 minutes I give out Starbucks Gift Cards as an apology. This 5 dollar gesture lets them know that their time is important.

4-      Access. When patients are sick and want to be seen, we need to see them. If that means working late or working through lunch we need to do that. If we are not available when they need us, what good are we to them?

5-      Timely responses. We need to return our phone calls every day and notify patients of test results as soon as they come in. Worried patients should not have to worry needlessly. When we communicate quickly we tell them we care.

6-      Listening. I am not a naturally good listener and I am easily distracted by the computer screen. I have trained myself to step away from the computer and to sit down when there is something important to communicate. A minute or two of my undivided attention means a lot.

7-      Eye contact. Computers make this harder, but it is important. No one wants to look at the back of our head when they talk.

8-      Clear explanations. Doctors too often rush through instructions at an unintelligible pace. In my office I type out instructions that the patient can pick up as they leave. I have learned to be specific and clear. I don’t just write “ice your leg three times a day”, I have learned to write “Ice your leg for 20 minutes three times a day.”

9-      Honesty. When I don’t know something, I say so. When something is outside of my area of expertise, I share it. Patients know we are human and appreciate it when we admit it.

10-   Time. Some patients need a lot of it. Instead of rushing and trying to handle 6 things in 10 minutes, I ask patients if it would be okay to bring them back in a week or two for a longer visit. When I say that I want to make sure I have enough time to address all of their concerns appropriately and that it is hard to do a good job when I rush, they always understand.

When I first started in practice I did none of these things well (I do not naturally communicate warmth, I am more of a problem-solver type). As a result my patient satisfaction scores were only average. It took years of effort to incorporate these behaviors into my practice. The result has been happier patients, high patient satisfaction scores, a happier office staff, and a happier me!

- Bart

Thanks for reading. Comments and questions are welcomed, and shares are truly appreciated (just click the button)

 

A Doctor Gets Fired Over a Dog

I had been there for her through her treatments for infertility,a long and  painful recovery from a motorcycle accident and a divorce. Our doctor-patient relationship lasted for over 15 years. It ended over a dog.

Even though she already had a dog, she moved into a new apartment that did not allow pets. Rather than find a new apartment or a new home for her dog she decided to have me write a letter saying that her dog was necessary for her mental health. She was happy with her dog and would be sad without it, which to her thinking meant that her dog was medically necessary. She scheduled an appointment specifically to get the letter.

As nicely as I could I informed her that it was my policy to never write letters for therapy pets. I explained that while pets do provide comfort that is not the same as a pet being medically necessary. As most of the requests I received were from patients who had not been previously diagnosed with a mental disorder I was concerned that I many of the requests were not genuine. As I did not want to make false or incorrect statements it was my policy to ask patients to direct these requests to their therapist or psychiatrist.

She was livid. Her voice rose as she sternly replied, “If you do not write me this letter I will find another doctor.” Never one to give in to threats, I wished her the best of luck with her new physician.

Requests such as hers have become increasingly common as more and more people have discovered the “letter from your doctor” loophole to pet exclusions. Privacy laws prohibit the disclosure of patient information to potential landlords so there is no way for anyone to confirm that a therapy dog is truly necessary. Many eager to please or afraid to offend doctors have joined in the deceit.

I realize that there are people who feel calmer and more secure when accompanied by a pet but I wonder if our society has not taken things too far. We have reached the point where people are averse to even the slightest discomfort. The feelings and comfort of others are ignored as personal desires have become God given rights. People are taking “therapy dogs” on airplanes, supermarkets and shopping malls. I have even seen them at Disneyland. (I would think that being at the “Happiest Place on Earth” would be therapy enough!) 

I have decided that it is not my duty to cater to every desire my patients express and that sometimes saying, “No” is the right response. I consider it a form of therapy.

-          Bart

Comments and questions are welcome. Click the subscribe button to have future posts delivered to your email inbox. The next post, coming on Monday, is the continuation of my series on the evil of adultery. Finally,  Yes those are my dogs in the picture!