The Value of the Physician-Patient Relationship

By Jaclyn S. Nadler, MD

In an age of metrics and data, it is almost impossible to quantify the importance of relationships.  When reading the article,”Trying to put a value on the doctor-patient relationship” in the NYTimes, I recall thinking well of course there is value to the physician-patient relationship.  It seems like a no-brainer, but how can you prove it. I cannot think of any physician who would argue that having a long-term relationship with a patient they have known over time and understands their family dynamics and personal stressors wouldn’t have a more solid base to draw upon.  The problem is how do you quantify it? How do you put a measure on a personal connection, on the ability to learn nuances about someone’s personality or the trust that develops over time between two human beings. Dr. David Meltzer, an economist and primary care physician attempted to do just that.  The results of his study supported his theory that strengthening the relationships between patients and their physicians can decrease medical costs and improve patient health. This is music to the ears of administrators whose primary goals are to improve outcomes and decrease costs.

But what about for the patient?  From personal experience I have seen patients crave personalized attention in our broken healthcare system.  With the push for corporate branding over the personal relationship between a patient and their doctor; patients are feeling like they are just a number.  They are shifted around to other “providers” for convenience and I believe to strategically destroy the bond a patient has with their physician and coerce their allegiance elsewhere.  Patients who are part of large healthcare organizations are not longer Dr. So and So’s patients but rather the patient of ACME healthcare. Patients don’t understand this, they come to us because their neighbor or friend recommended a specific physician to now find they are just a part of a large organization.  If their physician is fired or leaves the group they are many times given no explanation or information of how to follow that doctor; rather they are randomly assigned to a new “provider”.

Corporate medical institutions and insurers count on this.  They love the ability to manipulate patients at their whim. They do not want patients to have an allegiance to their doctors, otherwise they lose all the control.  As more and more physicians became employees it is harder and harder for them to have any direct control over their practice. With productivity demands, time constraints and so many interferences (EHR, regulations, etc…), physicians are losing the ability to develop these ever important relationships directly with their patients.  Our schedules are packed so tight, we find it difficult to add on sick patients who need to see us. With the implementation of patient call centers, patients are now diverted from being able to speak directly with the office staff who know them, to being funneled to eagerly waiting walk-in clinics and urgent care centers many times staffed with less qualified providers who do not have these established relationships.  This many times lead to delays in care and missed diagnoses.

Relationships are equally important for physicians.  Rushing people through, day in and day out, merely trying to get a glimpse of their health concerns and find a quick diagnosis to treat or more complex problems to refer.  Physicians do not have the luxury of time to let patients explain what ails them. I recall from medical school that if you listened long enough to the patient’s story, they would tell you what was wrong with them.  But in our current healthcare climate of 7 minute visits, patients are cut off too soon. Physicians are not given the time to properly examine and develop a differential diagnosis or the time to implement an appropriate plan of treatment.  We are not able to utilize the full extent of our knowledge since referring a patient to a specialist for something we could manage takes less time and is more efficient. Our time is cut short and documentation demands too high. We lose a critical part of what makes us a great physicians and that is the rapport we develop with our patients and the insight gained by seeing them over time.  Loss of this ever important relationship with our patients is an important contributing factor to physician burnout.

Patients need these relationships with their physicians to develop trust.  Trust allows them to divulge information they may withhold from someone new to them.  Trust allows them to feel confident in our recommendations for care. Over time that relationship results in a mutual respect for one another and aids in shared decision making which facilitates patient compliance and empowers patients to participate in their own care.  Anecdotally, patients frequently tell me how much they appreciate the time I take to explain a recommended treatment. I give them the risks, benefits and alternatives. I discuss evidence based medicine, but I also share what I have seen from experience. Because of our relationship they trust that what I’m recommending is in their best interest.  They trust me to take care of their family members. For me these relationships are what keeps me going. It’s the joy I get out of being a doctor.

Will we ever have data to support the value of the physician-patient relationship?  The above article definitely gives it some credibility. But for those of us practicing physicians, I say who cares.  Why do I have to prove to anyone other than myself and my patients that the time I spend and the relationships I develop with them needs to be quantified.  If these relationships make me a better doctor and my patients are getting better care for it, that is all that matters.

Patient call centers are BAD medicine

Jaclyn S. Nadler, MD

After reading the article,”Using Centralized Call Center Technology to Boost Patient Access”, I was very frustrated with the author implying that patient call center’s motives are to increase access to care and improve office efficiencies and the “patient experience”.  In reality, it is all about the money and controlling doctor’s schedules.

My favorite part is when she states they meet individually with their doctors to better understand their needs to make their day manageable; what a crock.  In the same breath it’s clearly stated that a “standardized schedule” is developed to maximize the physician group’s revenue and that is what it is truly all about.

There are many more pitfalls than benefits to a centralized call center: physician and patient dissatisfaction, non-clinical operators who don’t actually triage, delays in messages, patients sent to other “providers” which has the opposite effect of enhancing the physician-patient relationship they state it improves.  Corporate thinking is that patients are willing to just see anyone for convenience and not their personal physician, that they are willing to see midlevel providers when in reality most would like to see their physician who has the highest level of training and who knows their health needs better than anyone. In the article, Ms. Heath specifically lists goals that the call centers will ensure patients get an appointment with the “right type of provider”.  Well, how about they see their physician who can direct them to a specialist if even necessary. Call centers are not the answer. It would be much more effective to have mechanisms built into the schedule to ensure acute visit slots are more available, lessen physician workload so they can accommodate these patients rather than packing our schedules so tight we have no flexibility. Patient want and expect to speak to someone at the office who works directly with their physician and whom they’ve developed a relationship, not a faceless telephone operator.

Implementation and cost of these call centers is huge, in my previous job after the implementation of our call center, every time it was announced more operators (sorry, they like the term patient liaisons) were being added, all I heard in my head was cha-ching, cha-ching, cha-ching!  So, how are these call centers paid for? By the doctors of course who are required to see more patient to cover additional overhead expenses.

My second favorite part is how it will lower “physician burnout”, are you kidding me, all it does is add to more burnout.  See more and more people, get every open slot full or have your cherished patients sent to someone else who is “more appropriate” or has better availability.  

In my recent experience after our company implemented their new call center, much like the one listed in the article, patients HATED it.  They soon realized they were not speaking to someone directly in the office, there was a loss of the personal connection, delays in getting information to the doctor and inappropriate time slots utilized.  Recall the term “standardized schedule”, just say it like it is which is using the least amount of time possible to get the most patients in.

There are several inherent potential dangers of call centers such as patient being sent to urgent and walk in centers to see less trained providers and not allowing the individual physician’s offices the ability to appropriately triage and schedule high priority patients with their doctor.  Operators with no or minimal clinical training are able to place patients on the schedule without being properly triaged. I can list several examples of how this happened to me on a regular basis such as “severe abdominal pain” placed on my schedule 2 days later or an elderly gentleman with chest pain put in 15 minute slot at end of day.  What if this abdominal pain was a rupture appendix or the chest pain an impending MI. As a physician, I was very frustrated with the implementation of our call center, it was another mechanism for corporate medicine to control my practice, divert my patients elsewhere and not allow me to have a manageable schedule that was individualized to my and my patient’s needs.  My patients told me loud and clear they did not receive a better experience, they were just as frustrated when they realized they were not speaking directly with someone from the office, there was lots of miscommunication and mistrust.

Out of time

I am a physician.

I need more time.

I need more time to listen to my patients.

I need more time to perform a proper exam.

I need more time to collect my thoughts.

I need more time to document.

I need time to care for my family.

I need time to recharge.

I need time to eat healthy and exercise.

I need time to unwind.

I am a physician who is out of time.

Learning to love medicine again

There has been a lot of discussion about the state of medicine. Physicians face many challenges in our current healthcare system.  Long hours, liability concerns, electronic record documentation, ever increasing regulations, corporate interference, the need to make patients happy customers despite doing what is in their best interest and the list goes on and on.

Statistics show that almost 50% of the physician work force is burning out or already burned out; others such as myself prefer the term moral injury.  Physicians are taking their own lives at record numbers.  Everyone knows there is a problem, but no one seems to actually be doing anything about it. I’m inundated with emails, snail mail and articles about how to lessen burnout and improve physician wellness with little tangible measures to actually make a difference.  Many say take a yoga class or meditate; well when the heck am I going to do that when I don’t even have time to eat a real lunch?  Develop a better work flow, use a scribe or get your staff to do more of the administrative tasks they say; sounds good, but as employed physicians we are rather powerless, and in reality have no staff, the people we work with are also employees and any change must come from the powers above.

What most physicians don’t realize is they have a choice.  It’s not always an easy choice, but nevertheless the choice is still ours.  As physicians we need to stop allowing ourselves to be managed by those will lesser training or conflicting values.  We need to regain our independence.  Physicians by our training and professional nature were never meant to be employees.  Most of us would agree the work we do daily is a true calling, not a mere occupation.  We own our profession, not the insurance companies, big hospital organizations or the government.  These entities unfortunately have over time infiltrated our profession unknowingly to many of us and now physicians are in a terrible predicament.

I recently left a large hospital employed position.  Just for the reasons above.  I started my day at 6am reviewing labs that came into the computer overnight and completing paperwork I was too tired to complete at the end of my previous day.  First patient in at 8am, continued until 12:30p, no time for breaks and hard to even keep up with charting.  Lunch hour was drinking a protein shake, so I could continue to type or dictate my morning notes, refill prescription requests, review correspondence, call specialists if needed and answer nursing questions.  Most times I didn’t even get all that done before the afternoon patients rolled in.  Finished seeing patients around 5pm, sometimes as late at 6pm if complicated, then finished charting, afternoon refill requests and patient and nurse questions.  Most times left around 6:30-7pm.  Getting home to have a late dinner, maybe watch something on TV then off to bed to get up and start all over again.  Most times I did have some weekend time, but in our practice we took our own call which was 24/7 and any work required training was to be done on our own time, so frequently a few hours were put in on weekend also.  Now let’s discuss vacations.  What vacations you say! Most groups don’t have dedicated time for physicians to take a true vacation void of any work responsibilities.  With the advent of the EMR/EHR it is so easy for all that patient information to be readily available on our phones and computers. Many if not most physicians spend some work time on vacation.  I know in my prior practice it was impossible to get another physician to see a patient in your absence, they were generally referred to urgent care.  Messages/tasks continued to flow into my inbox daily with expectations for me to answer these promptly, there were no other docs to manage these minor questions.  Physicians don’t necessarily cover another’s inbox when lab and imaging results are coming in.  In some cases, you may have an excellent nurse or medical assistant to review and prioritize the abnormals, but I always feared I’d overlook a critical lab sitting in my inbox for days if I didn’t check it regularly while I was away.  Now some may say I was just being overly cautious, or not trusting the system in place, but in reality there was no acceptable system in place.  We as physicians bear the brunt of responsibility and I can count numerous times where things were overlooked and if I hadn’t continued to check my inboxes daily a patient’s health may suffer or care be delayed.  I can also bet, the administrators count on us to do this with no additional compensation.

Now to the part of loving medicine again.  Because of the long hours, no real time off, the push to see more and more patients in less and less time, while maintaining an excellent level of care and high patient satisfaction rate with no improvements in sight I became more and more disillusioned with being a doctor. I longed to have work-life balance, be able to exercise and take care of my own needs, as well as those of my family.  But even more I craved the ability to provide care on my terms, the way of was trained, not the way a corporate entity wanted me to.  I longed for the relationships with my patients, to know more about them as individuals so I could provide personalized care and not just treat only specific concerns or refer them out because I didn’t have the time to properly manage more complex health issues.  I not only needed more time in my life to recharge and enjoy my non-work time, but I needed more time with my individual patients to develop this relationship and gain their trust and confidence.

For many physicians this means taking a big step out of a false sense of security as an employed doctor.  For most, to truly be happy and love medicine again we need to find ways to become independent again; we need to remember what initially ignited that fire in us to become doctors in the first place and focus on incorporating it back into our practice and our lives.  We as physicians need time to recharge our batteries, eat healthy and exercise regularly, this not only improves our own health, but makes us good role models for our patients and family members. Sometimes we have to make difficult decisions like cutting back on material goods, driving less expensive cars, maintaining a mortgage within our reach, or having our children attend community college or instate universities with better tuition rates.

My way out was starting a Direct Primary Care (DPC) practice, I had the support of my husband, former patients many of whom followed me to my new practice and an amazing community of DPC docs who have mentored me along the way.  Only 5 months into my new independent practice I now finally feel free.  I practice medicine on my own terms, I have time to learn new things, I see about 1/5 of the patients I was seeing prior and enjoy the time I have with them to manage their health needs in a unrushed setting.  I have more time to counsel on diet and nutrition. I’ve regained an extra 4-5 hours per day to exercise, take a walk on the beach or just read a book for pleasure.  My pay is not what it was prior, but I suspect will get there soon.  Even with that, I am truly more happy and satisfied with my personal and professional life.  Most importantly, I am a better doctor for it.  Oh, and by the way I get lunch every day away from my desk and make a point to enjoy lunch with my husband out every Wednesday afternoon because I can.

A change is coming

Well another year has passed, nothing is changing, only getting worse. I continue to see the decay of medicine with physicians losing control of their profession. They are drowning in a sea of alphabet soup: MIPS, MACRA, NCQA, ACOs, APMs, CQM, HEDIS and the list goes on and on. Meanwhile, physicians are losing respect and being intentionally devalued. Corporate medicine is replacing physicians with much less trained substitutes under the guise of the term “provider”, purposely used to manipulate the masses. It’s time physicians #TakeBackMedicine and become leaders in healthcare and not mere pawns. We have more training than any other profession and should not allow outside influences to distract from the care we provide our patients and the time necessary in the exam room to learn about their concerns, take an accurate history and physical exam and make an appropriate DDx and then implement a plan. This interaction takes time and attention to detail and cannot be done in 8-10 minutes as our administrative peers would allow or demand. There are alternatives to corporate medicine.  While private practice has been plagued with the influence of insurance and Medicare’s ridiculous regulatory requirements, box checking, MOC and all that other nonsense has stripped physicians of being able to comply without enormous overhead; their is a movement gaining momentum that will turn our current state of healthcare on its head and allow physicians to practice independently again and work for our patients, not 3rd party intruders.  As I’ve said before, it’s ALL about the physician-patient relationship, in the end isn’t that all that really matters.

Be a positive change agent

There is so much negatively to our current health care environment. Physicians are integral to adding some positive change to this eroding health care climate. We as physicians and all of our health care partners need to bring the focus back to patient care. We need to get insurance companies, health care administrators and legislators to realize that exceptional patient care is paramount. When patients are being appropriately cared for the rest will follow. We need to also make our voices heard that the misappropriation of our time spent performing administrative tasks takes away from valuable clinical time. The question is, how do we accomplish this?

First, we need to put ourselves in decision making roles. Physicians should be involved in committees that are specifically tasked to look at these issues. We need to prioritize keeping abreast of the issues, so we can provide contributions to these discussion when they come up. We need to maintain certifications and additional degrees to allow us to apply for administrative positions to advocate for “physicians being physicians”.

How about in the exam room? This is where the majority of us excel. We need to remain focused on our patient. With all of the administrative pressures, we need to remain grounded and continue to fight the good fight. We need to prioritize excellent patient care. Take care of our patients the way we were trained to do and provide the best care we can with the limitations imposed on us. We need to stand up for what we know is right and chose our battles wisely. We need to realize our own worth and hold on that our value to our patients, consultants, healthcare groups, local hospitals and society is worth its weight in gold and will allow us to be positive change agents not only for our patients, but for the entire health care system moving forward.

Intruder in the room

Okay, I’m reading this awesome book, “The Digital Doctor” by Robert Wachter https://www.amazon.com/Digital-Doctor-Hope-Medicines-Computer/dp/0071849467 and I’m like this is so on point.  So much of the frustration I’ve been dealing with for the past several years has been put into print.  I’m only up to chapter 3 and it has been so enlightening.  I’ve always been aware of a physician’s focus on the computer to input our notes, quality measures and the endless amount of time spent entering orders to be done now and in anticipation of the next visit and how this takes away precious time from our interactions with our patient.

This book is great, it explains the history of why we are in the situation we are and explains some of the reasons for the awful dilemma.  If hindsight was 20/20, I truly believe we wouldn’t be in this current state, or at least not as deep.  I can’t wait to get to the next chapter and will definitely keep you all posted.

Computers are not bad things, they do amazing things, it’s just unfortunate that the government was placed in control of this and as this book highlights so were the computer vendors who sold their products more as billing tools to CEOs, rather than as clinical tools as they should have been to front line providers (nurses, physicians, mid-level providers, etc..).  I recall being an integral part of a previous company’s EHR committee and how the physicians were really frustrated by this focus.  My previous company was VERY innovative and progressive and understood the importance of having a strong physician presence on these committees was integral to physician buy-in at the practice level.  Those of us on the committee would consistently state our dissatisfaction that our current EHR was a billing tool and didn’t function as a patient chart.  The amount of time it takes to enter the billing info and the documentation to support it and all of the quality data has to come from somewhere, and that somewhere is during our face-to-face time with the patient.  Does this seem fair?  Why does the patient have to lose face-time with their doctor? Sometimes they are waiting months for these appointments, and when did we allow this to happen?

I plan to do more research on this question and will share with all.  Back in the day when we had the billing sheet, it took minutes, maybe even seconds to jot down a few diagnoses, labs or imaging tied to these diagnoses and a follow up visit.  The patient checked out and someone entered this info.  Now, in most cases the physician is the ‘data-entry’ person wasting valuable time entering data that any computer literate person could do and taking critical time away from the patient encounter.  Really!! When did physicians allow this?  I suspect when we became employees and allowed employers to tell us what to do.  But we need to speak up and let our administrative colleagues know this is not an acceptable use of our time and expertise.  That extra precious time should be used to have more time for the complicated 90-year old patient with multiple medical problems and/or dementia or to be able to get a sick patient in the office in a timely fashion or to have other openings to increase productivity (that should catch their attention).

I’d love to hear from those of you that use scribes.  I’ll admit I have not, but again I guess I still believe to some degree in the sanctity of the doctor-patient relationship and I can recall many visits with patients in the past, that if a scribe was present in the room they might not have disclosed very personal and critical information had we been alone.

The REAL question is, since I do not see computers in the rooms leaving any time soon; how do we work within the confines placed on us to provide the right care, give the patient the time and attention they deserve and still document accordingly?

 

Introduction to me and my blog

Hello all, please bear with me as I get acclimated to this new experience of blogging.  I would like to introduce myself, my name is Jaclyn Nadler and I am an internal medicine physician practicing in beautiful SW Florida.  I’ve been in the health care field for 30 years and have seen so many changes, most are not for the better.  I started out with ambitions of becoming a physician while in high school, and as life goes had financial struggles and obligations and was fortunate to meet my wonderful husband who encouraged me to go to college.

Being the first person in my immediate family to attend college this was a feat of its own.  I set off as a pre-med student at the University of Florida at the tender age of 17 only to realized I was not emotionally ready and definitely not financially ready to embark on this journey.  After one semester I headed back home and took on a job at our local grocery store.  This is where I met my husband, Kirk.  As I stated before, when he learned of my academic ambitions he encouraged me, or rather coerced me to go back to school (it was literally part of his marriage proposal) and I chose to pursue my early career in nursing.  At the age of 19, I enrolled in an A.S. nursing program and set out my career in health care.  I embraced nursing and the focus on holistic patient-centered care.  I eventually worked towards my BSN, then my MSN specializing as an acute care/family nurse practitioner working in an interventional cardiology practice.  I thrived in this environment and continued to want to do more.  Although my nursing career was very fulfilling, I missed the accountability for my patient’s care and always felt that I was only tangentially involved.  This by no means trivialized my NP role, but personally I did not feel the professional satisfaction I was seeking.

Once again, my husband sensed this and asked what it would take for me to attend medical school.   Between my nursing degrees I has considered this, so had fortunately completed the majority of my pre-med prerequisites; all that was needed was 3 additional classes and my MCAT.   We decided to take the plunge, I went part-time at work, completed my courses, took my MCAT and applied.  I was accepted at the University of Miami and the rest is history.  I went on to complete a wonderful residency program at Wake Forest University in Winston-Salem, NC and practiced in an internal medicine practice there for several years, before heading back to Florida.

Since that time, I have held multiple clinical and administrative positions.  Over the past 30 years I have seen remarkable advances in medicine, but I have also seen the destruction of the health care system.  Having had a strong nursing career (bedside nursing, administration, long-term care and working as a nurse practitioner), and now a successful medical career, both clinically and administratively I have seen the shift from physician entrepreneurs to being commonplace employees.  While physician employment in itself it not the issue, being treated as an employee has stripped away our focus on the patient and rather placed it on our employer.  I’ve watched how non-physician executives and administrative staff TRY to dictate how many patients we see, how much time we have to see them and in many cases attempt to tell us how to take care of them.  Clinical “guidelines”, while the intent was noble are being used as rules of care rather than guidelines and the value of my training and experience is beginning to fade.  I no longer feel that my relationship with my patient or the quality of care I provide is paramount, but rather complying with the rules imposed by employers and the completion of EHR documentation and quality care metrics is the standard now required of being a “good doctor”.

The intent of this blog is multifaceted; first it allows me a place to share these concerns with others, to gain valuable shared experiences from my front line colleagues and hopefully at some point along this journey will allow us to learn from one another, instill change and bring back the value and irreplaceability of being a physician.  My wish is that someday in the near future, physicians will regain their rightful place as leaders in health care and no longer be viewed as commodities.  My goal is to empower physicians, one doctor at a time.

Since successful health and patient care require the input of so many important team players and disciplines; I encourage participation from all involved.  I would love to hear from nurses, nurse practitioners, physician assistants, social workers, pharmacists, PT, OT, ST and so many other wonderful people, since I know these changes affect all of us.  I challenge the engagement of health care administrators, CEOs and politicians since these are the folks who can help us implement these changes.

I am hopeful in the next few months to provide weekly blogs about the current state of health care, challenges physicians are dealing with on the front lines, ways to implement change and ways we as physicians can empower ourselves to have our voices heard and help to heal this broken system.  I will also share pertinent stories and blog points from others, as well as resources we can all use in our daily lives and practice.  I am very optimistic as a collective effort we can do this.  Embark on this journey with me to instill some positive change in the world and definitely our cherished profession of medicine.