Point of view: The fall of the clinician-patient relationship | SehndeWeb

By Mary Dudzik, MD

I read Jill Goldthwait’s column in the newspaper last week with a combination of sadness and relief that someone was talking about the loss of humanity in health care. I was particularly struck by the last two lines: “We want our caregivers to have time to see us, to hear us. We want them to have time to occupy themselves.

Believe me, health clinicians want the same thing. I use the word clinicians to encompass physicians, physician assistants, and nurse practitioners because many of us don’t like to be called “providers.”

This month of June will mark 30 years since I completed my family medicine residency in Bangor. I will be forever grateful that I spent the first 20 plus years doing what I was trained to do, doing what I loved, practicing full spectrum family medicine. I got to see all ages, see people in the ER and in the hospital, see people in the office, give birth and care for them as they grow up, and see people in nursing homes. Seeing people in each of these places, when they were most vulnerable, was how this “personal, even intimate” relationship that Ms Goldthwait refers to evolved.

But slowly and insidiously, health care has changed from a service I was proud to be a part of to a business that embarrasses me. At every turn, it’s nearly impossible to care for patients the way we used to, the way we wanted. I don’t see patients in the hospital anymore because most hospitals want their inpatients to be looked after by hospitalists, clinicians who only see inpatients and have no connection with them otherwise. I respect hospitalists and the work they do, but I will always feel that patients would rather see their trusted family doctor when they are sick than a stranger. Additionally, the administrative burden of seeing a patient, whether in the hospital or the clinic, has gotten out of hand. I used to be able to see a few hospital patients, as well as a new mother and her baby, before going into the office. Now, there just isn’t enough time, primarily because of electronic medical records and the enormous amount of time and attention they take away from patient care.

It’s hard to point to a single thing as the one thing that has poisoned medicine, but the electronic medical record (EMR) is certainly in the running. Don’t get me wrong, there are some things about it that are great. For example, I like being able to electronically send drug refills to the pharmacy with the click of a button. However, EMR records are no longer a mere note of what was discussed, what was done, and actions taken by the patient and clinician, which they used to be. Rather, it is a complex billing document that is reviewed by insurance companies that don’t even care a bit about the type and adequacy of care provided. It is often difficult to sift through notes to find the information needed to care for a patient because it is obscured by unnecessary and irrelevant information. But unless this information is included, unless specific phrases are used, unless specific boxes are checked, payment to the healthcare organization/clinician will be reduced or not paid at all.

EMRs have also completely distorted the clinician-patient relationship. Prior to EMR, records were in paper files. The only information they contained was medical, no billing information or busy work. They weren’t perfect, but it was much easier to sit down with a chart and flip through it and maintain eye contact with a patient. With EMRs, it’s tempting to stand in front of the screen and stare at it while talking to a patient. I can honestly say that I don’t do that. The main reason isn’t because of the EMR distraction, it’s because I know I’ll learn more about a person by looking at them and talking to them than on a screen.

I understand the temptation for a clinician to look at the computer and type on it during a visit. These people are trying to protect their free time, which is disappearing. People have no idea how much time EMRs have added to our days. It is estimated that for every hour we spend in in-person care with patients, we spend two hours in the EMR documenting the visit, completing requirements, invoicing, and performing other administrative tasks. I think that’s correct. Clinicians spend hours before and after work doing this data entry, this busy work that for the most part has nothing to do with patient care. And most of us only get paid for the hours we spend seeing patients.

So what are the solutions? As we know, there are things medical practices can do, and some are already doing, to try to provide patients with a personal service rather than a commercial transaction. I am fortunate to work in a practice with four clinicians in their 50s and one in their 20s who value the clinician-patient relationship like me. Every day we go over our schedules and if someone sees one of my patients and I see one of theirs, we just swap (after confirming that the patient is okay) to foster continuity and a ongoing relationship. We see if and where in the schedule there is room to insert a patient who must be seen that day. We do our best, but we can’t always do everything.

I also believe that a single-payer/Medicare-for-All system would greatly improve the lives of patients and all who care for them. There is no reason for health care to be linked to employment. It is a human right and should be granted to all. The number of people I see who have put off medical care until age 65 because they could not afford it is appalling. By the time they show up for that first Medicare exam, their diabetes has already caused kidney damage, their cancer has already progressed. Not to mention the countless others who never reached 65. A single system, if done right, would allow the money invested to go into patient care and the organizations and people who provide that care instead of the many insurance agencies whose CEOs make millions of dollars. every year, who each have ever-changing rules about what they will and won’t cover (most of the time won’t cover) that we have to try to stay on top of, whose primary guideline is to ensure profits for their shareholders, not to secure the health of a population.

Health care was never meant to be a for-profit business. It was supposed to be a service for all. What we are doing is not sustainable. This country spends more on health care than any other country and has the worst results. Time to change. Our lives depend on it.

Dr. Mary Dudzik is a family physician in Bar Harbor.

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