Patients are Not Happy

Perhaps the only people more unhappy with the medical system than doctors are their patients.  The other day I overheard a conversation in my chiropractor’s waiting room.  A well-dressed, articulate woman was telling the receptionist about her mother’s hospital experience, which involved transferring from the local community hospital to a larger teaching hospital for emergency surgery. “No one told us what was going on” she told the receptionist, “so I went up to her doctor and said, ‘ Do you have a minute?’  He looked right at me and said ‘No, actually, I don’t’ and walked away!” 

I cringed when I heard this.  I actually know the doctor she was referring to and had always found him to be a caring professional.  Yet he didn’t have a minute to talk to this sick woman’s worried family, or even 10 seconds to say “No, I don’t right now, but if you give me a number where I can reach you, I will call you as soon as I do.”

Just the other night my mother, who is an RN, shared with me her disappointment in her new doctor.  She chose this doctor because she was a female, close in age, and she had hoped that as medical professionals they might connect.  “I went for a physical and, except for putting her stethoscope to my chest, she didn’t even touch me”.  She told the doctor that she had recently been waking up in the night with palpitations.  According to my mother, the doctor didn’t even try to figure out the cause of this new symptom.  “She didn’t even ask me any questions!”  

I suspect that this busy professional was trying to cut corners with her relatively healthy patient so that she could have a few more minutes with her sicker ones.  Still, it is hard to justify a doctor not touching a patient during a physical exam. Worse yet, how can a potentially serious symptom of a cardiac nature not warrant a few questions and some simple tests?  I found myself wondering if I will become like this doctor after a few more years on the medical treadmill, going through the motions of treating a patient without actually caring. 

Consider now the sicker patients, such as the growing elderly population.  I feel terrible for my older patients as they attempt to navigate this new complicated medical world of computers and rushed appointments.  The sheer effort they make in preparation for their longed-for face time with me is daunting, often including planning months in advance to coordinate rides with busy family members.  For many lonely older people, this much anticipated visit is a disappointment.  Sifting through the pile of medications and discussing their most pressing health issues takes precedence over socializing. 

And, truth be told, they really don’t want to be on all of these medications that they can’t afford on their fixed incomes.  Many elderly patients take more than a dozen medications, collected from multiple specialists that focus on one organ at a time. This vulnerable population is afraid to have more tests that may find something else that needs to be treated and may not be covered by their insurance.  What they really want is a quick check up and to talk about their worries, like their loss of independence or grief over passed family members.  They are afraid of the very real possibility that they may spend their last days in a nursing home.  They lament the old days where they could die quietly in their homes surrounded by loved ones and supported by their trusted family doctor.  As one elderly patient of mine said when it was suggested that with his good health he could live to be 100, “How dare you!”  

Electronic medical records (EMR) have further exacerbated the lost human touch between doctors and patients.  Patients are uncomfortable sharing intimate health issues to a doctor staring at a screen.  I used to sit next to my patients so that I could look them in the eyes and reach out to touch them if they were upset.  I would occasionally scribble down a few pertinent details about their symptoms while I sat there so that I could remember them when I dictated my notes later.  Now I stand in front of a screen, looking over and around it to see my patients. 

In addition, the computer actually keeps track of how much is accomplished by me while I am still in the room with a patient (the efficient doctor does their charting with the patient present).  A weekly “pulse” alert compares me to both my peers and to an idealized gold standard of proficiency in areas such as orders entered while still in the exam room and charting completed within an hour of patients’ visit, both of which compel doctors to type and talk simultaneously.  EMR also provides easy access for insurance companies to collect data about patient care that effects reimbursement.  In a diabetic, for example, insurance companies look at how well the blood sugar is controlled and whether there is documentation of yearly eye exams, foot exams, and urine tests.  If these variables are not properly documented, even if they are done, it is a mark against a doctor ultimately resulting in less pay for the office.  This contributes to the compulsion to input the information immediately, rather than take a chance and forget to document it later.

Another new trend in medicine is called Patient-Centered Medical Home (PCMH).  This was developed to assist in accountability and hopefully better patient care.  In reality, it amounts to pushing a lot of virtual buttons on the computer screen.  In order to meet EMR standards for PCMH, I must click a button labeled “Mark as Reviewed” in multiple sections of the electronic chart (vital signs, problem list, medication list, and allergies) even if these were reviewed and recorded by my nurse.  Pressing this button doesn’t actually insure that I did review the section, it just means that I pressed the button.  Searching out and pressing these buttons on the screen distances me even more from the patient in front of me. I feel like a mouse in an experiment where, if I learn to press the right buttons, my hospital will be rewarded financially.

I am not opposed EMR.  In fact, I truly believe that the improvement in documentation and accessibility will eventually result in better patient care.  It is just hard to understand how pressing buttons, placing orders and charting in the exam room will accomplish this. On the contrary, my attention is diverted away from the patient in front of me.  Better patient care would more likely arise from showing patients that their concerns are not only noted in the computer, but actually heard.  It is really quite simple:  look at the patient in front of you, listen to what they are saying, hug them when needed.  

Patient care promises to become even more challenging as the population becomes sicker than ever, increasing demands on an already overtaxed and under-staffed system.  The rise in stress-related illnesses, the epidemic of obesity and diabetes, the growing elderly population as baby-boomers age, the undertreated mentally ill, the plague of young drug-seekers, the uninsured poor – it is enough raise my own blood pressure.   If our society as a whole, led by forward thinking medical professionals, prioritized wellness and put their efforts into prevention, I am certain we would not only make tremendous health gains, but would also save a lot of money.  This seemingly obvious conclusion was not something that was taught in medical training, but rather something I discovered on my own when I realized that my own health was at risk from stress.