Special note: As I write and publish this particular blog I want to be clear that it is not intended to be a political commentary or an endorsement of one party’s particular politics. It is intended to be a comment on the forces that are influencing the way in which doctors must practice medicine in the US today.
The practice of medicine has always been more of an art than a science. The great physicians of the past such as Sir William Osler and his contemporaries understood the importance of the history and physical exam. These great diagnosticians talked to their patients and listened intently as the “story” of a particular disease process unfolded before them. This week, I read an essay by Dr Bill Frist published in The Week magazine. Dr Frist describes his experiences as Senate majority leader as it related to discussions of healthcare reform. I was not surprised to learn that most of the discussions about healthcare policy and reform involved politicians, academics, regulators and lobbyists. The professionals affected most–practicing physicians in the trenches who care for patients every single day– were not even at the table. In the article, Dr Frist interviews his own Internist and asks about how healthcare reform decisions affect his ability to practice medicine.
Several points from the interview stand out and warrant careful review and comment:
The Effect of EMR:
A busy Internist may care for thousands of patients. Instead of getting to know their patients on a personal level and listening to the “story” unfold in the office visit, physicians are now pecking away at a computer and checking boxes during the allotted 15 minutes. Often, government regulations require that certain questions be asked and documented in the EMR even if they have no relevance to the patient visit. EMR use is important and has many benefits but the computer now can be a barrier between doctor and patient in the exam room. The art of taking a history is to allow the patient to talk and guide discussion. Many times, facts that are critical to accurate diagnosis can be found when the patient is able to tell his “story”. When clicking required boxes on an EMR, the physician may unwittingly force the discussion and miss key components. Rather than being allowed to speak freely during the visit, the patient may be simply interrogated by the physician at the hands of the EMR and its boxes that must be checked.
Regulation to Reduce Waste:
Proponents of healthcare reform will argue that regulation will reduce waste and abuse. In fact regulation and increased demands on providers are beginning to have just the opposite effect–more unnecessary paperwork and “box checking” leads to less time actually caring for the patient. With the expansion of healthcare, physicians are asked to care for larger patient loads with less time and with more regulatory red tape. Again, this leads to less time for listening to the “story” each patient so badly needs to tell. Moreover, physician burnout and depression are becoming more commonplace. Increased workload, increased unnecessary and redundant paperwork (even if electronic), decreased reimbursement and ever decreasing quality time with patients significantly contributes to feelings of diminished satisfaction at work. Recently, a blog on physician burnout published in the New York Times addressed these very issues.
Evidence Based Medicine and Quality Care Measures:
As Dr Frist so clearly points out, checking boxes to meet quality care measures is not what improves care. Compassionate, thoughtful and scientific analysis of a patient’s “story” leads to accurate diagnosis and treatment. Treatments based on the best available data produce the best possible outcomes. Physicians must continue to blend art and science in order to make rationale treatment plans individualized to each particular patient. As Dr Frist mentions this cannot be accomplished by “mindlessly checking boxes”. Clinical trials and data certainly should guide the way in which medicine is practiced. However, in medicine there are no “absolutes”. In training many physicians were taught to never say “never or always”–we must remember that today as well. Data guides practice and evidence guides decision making but clinical judgement–not “box checking” is what makes good physicians great.
The Bottom Line:
Healthcare in the US is in transition. All of us agree that the system does not work well in its current form. Politicians, lobbyists, regulators and academics have shaped the path of reform thus far. Physicians must be involved in the planning of the future healthcare system in the US. Although quality of care for our patients is paramount, physicians must be allowed to practice with both the art and science of medicine. Paperwork, performance measures and “box checking” are beginning to separate patient from physician. We must return the focus to our patients–we must listen to “story” that unfolds in the exam room in order to improve outcomes and impact disease.