Tag Archives: doctor-patient relationship

Big Brother is Watching…And Your Healthcare Privacy Rights May Suffer: More Affordable Care Act Fallout

Data is essential in healthcare delivery and it is often what guides us in improving outcomes.  Utilizing data obtained from large populations helps us better decide what aspects of disease prevention and treatment need more of our attention.  I have shared my concerns about the sanctity and security of these data in a prior blog from July.  These data are important and allow us to evaluate at risk populations and target our interventions.  In the US, participation in surveys is 100% voluntary.  The Centers for Disease Control obtains most of its data from diagnoses reported by healthcare institutions (there are certain disease that are mandated by law to be reported).  However, with the advent of the Affordable Care Act (ACA), some corporations and businesses have taken the acquisition of data a step too far.  In George Orwell’s novel 1984, the author presents a vision of an dystopian society where “Big Brother” watches every move ordinary citizens make in an attempt to maintain order (and advance his own agenda).  We have all seen the recent government abuses within the National Security Administration (NSA) and within the Internal Revenue Service (IRS).  As the ACA is implemented, I am concerned that Big Brother may already be here and working in the US healthcare system today as well.  In medicine, the doctor-patient relationship is sacred–data disclosed for healthcare should be sacred as well.

Although our country has always been based on basic tenets of freedom of choice, right to privacy and other key freedoms, some institutions see Obamacare as a ticket to interfere with the daily lives of American citizens.  For instance as reported in the last several weeks by the New York Times,  Pennsylvania State University now is attempting to require all employees, including senior faculty, to undergo physical exams and answer online health questionnaires that contain very personal and very sensitive health information.  It is obvious that the pressures of the ACA and the need for cost containment is motivating these types of mandates.  From the business standpoint, the university is hoping to reduce risk and liability by modifying at risk behaviors in its insured employees.  However, none of these data will help the faculty do a better job for their employers and I am sure that the Penn State University administration clearly see this as a way to save healthcare dollars.  The next logical step, however, may be to deny or terminate employment based on health risk and potential cost to the system.  Where does the rabbit hole end?  Is this the beginning of health status discrimination in the workplace?

Many senior faculty at Penn State are refusing the mandate based on invasion of privacy–even though the university is planning to levy substantial daily fines for non responders.  Several prominent professors have stated that if they are forced to participate they will simply answer the questionnaires randomly and provide far fetched ridiculous answers–simply play the conscientious objector.  Many other Americans are waiting to see how this pans out–there is concern that this type of activity will begin to spread to other institutions and industries.  Labor unions are already beginning to lobby against these mandates–in the case of Penn State, union employees are exempt.  At what point are our private lives and medical histories private?  What is the separation between workplace and home? Where do we draw the lines and do we allow others (government and employers) to draw the lines for us?

The spirit of risk reduction and working with employees to improve their health status and live better lives makes good sense–however, there are better ways to accomplish this goal.  Health fairs, educational seminars and free health screenings for cholesterol and high blood pressure make good sense–but all of these activities should be voluntary.  Asking highly personal questions such as sexual preference, prior drug or alcohol use and the state of one’s marriage should not be a part of a wellness program at work.  In the case of the Penn State questionnaire there are even questions related to how you get along with others in the workplace–including your boss.  These issues are private and should remain that way. In defense of the institution, the development of these wellness programs are not entirely their fault.  In fact, the ACA provides a 30% discount for the implementation of a comprehensive wellness program–virtually assuring that every business will “voluntarily” submit to these types of invasion of privacy. Although the university administrators claim that the data is secure and is not available to supervisors and those in the administration, it concerns me greatly that this will not be the case– (just ask those Americans who had unlawful wire taps and those that were bullied by the IRS due to their associations with certain political groups).  Big Brother is watching….from your doctors office, from your bedroom and from your back porch.   I am afraid that this particular blog may leave you with far more questions than answers….maybe we should ask Big Brother.


Considering A Divorce From Your Doctor? Here’s What You Need to Know

Just As in marriage, the ability to communicate is essential to any successful doctor-patient relationship.  In fact, the most successful doctor-patient relationships are a lot like a marriage.  Both parties must be willing to listen, to negotiate and to support each other’s decisions.  As I have stated in many previous blogs, outcomes improve significantly when patients are engaged in their own healthcare.  Engagement only occurs when doctors and patients are able to effectively work together to solve health problems.  The days of the paternalistic physician dictating lifestyle changes and treatment plans are long over.  Today, patients are better informed and armed with information as they enter the office for consultation.

Unfortunately, just as in marriage, not all doctor-patient relationships work out.  Sometimes changes have to be made in the spirit of moving forward with effective healthcare. This week in the Wall Street Journal, author Kristen Gerencher addressed the issue of “When to fire your Doctor”.  In this piece Ms Gerencher provides sound advice on how to determine when it is time for a change.  She mentions 5 warning signs that may indicate that a divorce and remarriage to another provider is important.  In particular, if you feel worse when you leave your physician’s office than when you arrived, it may be time to consider a change.

Here’s my take on the warning signs that the WSJ mentions:  (the warning signs listed are directly from the WSJ article, the commentary below each one is mine)

1. You leave with more questions than answers.  

It is critical that physicians take the time to communicate clearly to patients.  Essential to this communication is allowing time for questions AND clarifying any misunderstandings or addressing concerns about a treatment plan.  This can be challenging for doctors in the current healthcare environment where federally mandated documentation requirements and pressures to see more patients in less time are limiting the time once dedicated to patient discussion.  However, it is essential to the health of the doctor patient relationship that physicians do not allow these conversations to be pushed aside.  Remember, patient engagement is key.  An informed patient is much more likely to be engaged.

2. Your doctor dismisses your input.

In the age of the internet, patients often come armed with lots of information (lots of which is unreliable and shady at best) that is obtained from online searches.  Rather than simply dismiss the information as junk, it is important to guide our patients to more reliable and more accurate sources of internet information such as MedPage Today and other good patient friendly information sites.

3. Your doctor has misdiagnosed you.

Medicine is not a perfect science.  It is important that you work with your doctor every step of the way along your path to diagnosis.  Mistakes in diagnosis happen–however, these mistakes are not always negligence.  Consider if your physician has carefully considered your problem and has provided a well thought out differential diagnosis before leaving due to a misdiagnosis.  It is important that communication continues during the process of misdiagnosis.  If there is no good communication at this stage, it may be time to choose another provider.

4. Your doctor balks at a second opinion

A good physician is never afraid of a second opinion.  In fact, I often welcome a second opinion in cases where there are multiple choices of a plan of action.  It is essential that patients feel comfortable with their treatment plan–a feeling of comfort breeds engagement and engagement is key for success.  As physicians, we must be willing to put our egos aside in order to provide the best possible care for our patients.

5. Your doctor isn’t board certified.

When choosing a physician, it is vital that you examine his or her background and training.  Typically, doctors must complete a course of training in residency and fellowship in order to be boarded in a particular specialty.  Board exams (some written and some oral) must be passed and competency must be proven.  Once certified, physicians must maintain competency through continuing medical education and re-certification every 10 years.  If your doctor is not board certified, it is not necessarily the end–ask why.  There are several reasons that they may not be including overseas training that is not recognized in the US by the US societies responsible for board certification.

Choosing a doctor is a lot like choosing a spouse.  Decisions should be made in cooperation with one another and both sides must contribute to planning and execution of the chosen course of action.  Patients must weigh options, consider pros and cons and discuss issues with their provider and the provider’s staff when unhappy with a particular physician or physician group.  IF communication is not productive and there is no engagement, patients must make a change.  Good healthcare is a two way street.  Doctor and patient must work in concert in order to achieve optimal outcomes.



Please Log On and Focus Your Webcam: The Doctor Will See You NOW!

It may seem like science fiction from an episode of the once popular futuristic cartoon series The Jetsons, but virtual doctor visits are now here.  As chronicled in a recent New York Times article, insurers are now rolling out services where patients can interact with physicians via webcams and receive treatment for minor illnesses.  Obviously, the insurance companies are motivated by lower costs–however, with a soon-to-be flooded healthcare system in the US today, virtual consults may also be able to ease the primary care shortage.  However, these novel doctor-patient relationships are not without controversy.  Many physicians warn of the incompleteness of the evaluation without a physical exam.  Government regulators worry over the lack of oversight–in fact, only 13 states actually recognize virtual visits as a true doctor patient interaction allowing the physician to prescribe drug therapy.  Many attorneys see this as an opportunity for even more lucrative (and frivolous, in my opinion) malpractice litigation.  But, ultimately, we must find new ways to simultaneously decrease healthcare costs, improve outcomes and reach the millions of Americans who desperately need  medical attention.

The idea of webcam medical visits is not a new one.  Many doctors in remote locations have used virtual consults to help make diagnoses.  In a recent bestselling book, Nantucket surgeon Dr Timothy Lepore writes about using electronic visits with specialists in Boston to help triage patients for medical evacuation to the mainland.  In this particular application of virtual medicine, a specialist or colleague is used to provide a second opinion;  the patient is still under the direct care of a physician who is present at the bedside.  However, the virtual consult proves critical in the decision of whether or not the patient should be flown to Boston for more advanced care (at significant expense).  I believe that webcam visits, when used in this context, can meet the goal of significantly decreasing unnecessary expense while at the same time improving care and impacting outcome.  Moreover, specialists are able to support general surgeons, family physicians and internists in underserved areas on a routine basis.  Rather than waiting for a cardiologist to show up to see patients in person once a month on the island, the cardiologist can see patients daily via virtual visits.  Care becomes more efficient and remains centralized through the primary care provider.

In contrast there are other things about remote physician visits that are less than ideal.  In my previous blogs, I have written about the critical nature of the doctor-patient relationship.  It has been shown in many different studies that engagement of patients in their own healthcare clearly impacts outcomes.  I worry that in routine visits with a virtual doctor that no real engagement can occur.  Regardless of all the fancy bells and whistles now available to physicians, the practice of medicine remains a very personal and human relationship.  Eye contact, gentle touch, non verbal cues and body language–all important in a human relationship–do not translate well to a virtual visit.  Much of the art of medicine is found in the relationship between doctor and patient.   In all fairness, there are ways that relationships can be built via virtual visits–regular webcam “appointments” with the same provider will go a long way to making the best of the lack of physical presence.  Just as in a regular doctor visit, follow up is critical to success.  From a diagnostic side, much information can be gleaned from the physical exam.  In a virtual visit, observation is still possible but there is no way to place a stethoscope on the chest or to palpate the abdomen.  Many of my mentors in medical school stated many times over my years of training that “80% of diagnosis in medicine is the history and physical exam”.  This lack of a physical exam cannot be bridged or replaced without a physician at the bedside.

As in most areas of medicine, government regulation will be looking to play a major role in virtual medicine.  Currently only 13 states recognize webcam visits as an actual physician encounter.  In order for for a physician to legally prescribe a medicine, a well documented visit must occur.  For virtual doctor visits to be a viable option, legislation must address these types of visits.  In addition, medicare and other third party payors must be given guidelines and codes (yes, more codes) in order for billing and reimbursement to occur.  For physicians, particularly in this time of declining reimbursements, adequate compensation for time spent in virtual office visits and consultations must be quantified, defined and approved by both insurance companies and government agencies alike.

Lastly, we must deal proactively with the inevitable litigation that will come with webcam or virtual physician encounters.  I am certain that the trial lawyers out there are already looking into ways in which virtual physicians can be sued.  In order to have any opportunity to curtail healthcare costs and implement remote medicine, we must continue to push for tort reform and limit the activities of litigation-happy attorneys.  That topic, however, is much too big to address here–it will require its own blog entry altogether.

Ultimately, I believe that virtual medicine and webcam consultations will be an important part of medicine in the future.  However, there are many challenges that must be faced as we implement these new technologies.  Most importantly, we must preserve the art of medicine and continue to provide excellent patient care.  Physicians, insurance companies, government agencies (and even trial lawyers) must work together to make these new innovations both possible and cost effective.