27 Feb Distracted medicine
Everyone knows distracted driving poses tremendous risk for one’s personal safety, as well as all others in the vehicle and on the road. Drivers however, are far from the only ones distracted today, and a recent study out of Fort Worth, Texas, suggests your doctor may be practicing distracted medicine.
Dr. Richard Young, the family practice residency program director in Fort Worth Texas, conducted a fascinating study recently published: (A Time-Motion Study of Primary Care Physicians’ Work in the Electronic Health Record Era). The study is based on observing family physicians in an Ambulatory Care Clinic during over 900 visits affiliated with the Residency Research Network of Texas. These family doctors were intentionally chosen to reflect a wide range of patient care styles. The research involved measuring how much time each physician spent with the patient, (let’s call this “FaceTime”) versus how much time they spent before, during and after the clinical encounter interacting with the electronic health record (EHR) (let’s call this “Screen Time”).
The average patient encounter in this study was 35.8 minutes. Of this time, 18.6 minutes were devoted to screen time. This means the physician on average was spending less than 50% of the time available, to listening to the patient and to addressing their needs. Another interesting fact in this American study is that the average number of problems with which patients presented was 5.4.
Dr. Robert Wachter, a professor and chair of the Department of Medicine at the University of California San Francisco, presented data at the 2017 American Conference on Physician Health where he outlined the results of a 2016 survey of 6375 doctors in the United States. This large survey identified that 84% of the physicians were using Electronic Health Records (EHRs). These physicians reported “feeling less satisfied with the amount of time they spent on clerical tasks. They also were found to be at higher risk of professional burnout.” (Electronic Health Records contributing to Physician Burnout). A smaller study from 2014 involving 370 family doctors showed those who used EHRs most, reported feeling greater time pressures associated with significantly more burnout, and were more likely to leave their medical careers prematurely (Electronic medical Records and Physician Stress in Primary Care- Results from the MEMO Study 2014).
The electronic medical record was supposed to improve patient care and physician satisfaction. In Canada, the physician is paid for the clinical encounter on the basis of a diagnostic code. If a patient presents with more than one complaint, the physician is not paid any more for managing these subsequent complaints. This most recent American study suggests patients may arrive at the family doctor’s office with five complaints while the physician can only legitimately bill for one of them. Some clinics now post in their waiting rooms that only one complaint per visit is allowed under the publicly-funded healthcare system in Canada.
To be fair, there are exceptions to this with respect to complex case management, but one must be chronically sick with several diagnoses in order for the family physician to bill OHIP in such instances. Most often, patients come with multiple complaints of which many are simply functional and therefore don’t lead to a diagnosis. They do however, require reassurance to avoid the unintended consequences of stress and worry.
I spent more than 30 years in emergency departments while simultaneously running my Aviation and Executive Medical Practice. The difference in practice styles was dramatic. I would sometimes see 50 patients in a six-hour shift in the ER and perhaps 10 to 15 patients during a clinic shift. The ability to gather important medical information, perform a physical examination, and reassure the patient that they are well, or more importantly appropriately managed, was entirely different in the two settings.
The solution to providing effective care to patients is to ensure physicians have enough FaceTime to ensure patient satisfaction. Included in the time necessary to take care of a patient, the physician also needs to have an efficient electronic medical record and enough time to enter relevant data. As the public health care system is increasingly constrained to provide care to a growing aging population, and the requirements to document health care encounters using electronic medical record increases, patient needs are gradually being squeezed out of the traditional doctor-patient encounter. It is no wonder one million Ontarians do not have primary care physicians, and that most family doctors over age 50 are contemplating earlier retirement than they might have otherwise.
I am a strong supporter of a centrally managed, government controlled health care system. This is because the government has an obligation to ensure every citizen is provided with appropriate healthcare. However, in Canada, there is only one payor and so health care delivery is effectively monopolized by only one stakeholder, the government. Patients are left out of talks between physicians and the government when physician remuneration is being negotiated. The result is a kind of ‘musical chairs’ where the government removes funding for various previously funded services (such as the annual physical examination) and that physicians are left with having to limit FaceTime with patients and to addressing only their most pressing complaint. The solution is to have a centrally managed system that allows for additional payors, such as corporations, organizations, individuals and supplementary health care insurance.
The World Health Organization publishes a healthcare report card for every country approximately every five years. Most often, the top five are European and Scandinavian countries. These top performers have systems run by the government but funded by at least two or three additional payors. With more financing entering the health care system, health care outcomes are better. Canada currently ranks 30th out of 191 countries, the US 37th. (http://thepatientfactor.com/canadian-health-care-information/world-health-organizations-ranking-of-the-worlds-health-systems/)
Deerfields Clinic is not a private medical clinic. In fact, what Deerfields does is provide services no longer funded by the health care system. The list of un-insured services has been growing steadily over the past 15 years as a result of government-physician contract negotiations. I practice both conventional medicine and functional medicine. Conventional medicine is the medicine taught at University-based medical schools and regulated by State Medical Boards and provincial colleges. It is essentially preoccupied with the diagnosis and treatment of disease. Functional medicine is a science-based approach to the biological factors that can lead to disease, and is typically not an insured service. For example, engaging your family doctor in conversation about nutrition, fitness, stress, sleep and toxins is no longer possible unless you already have a disease for which there is a diagnostic code. And yet, it is self-evident to everyone that one’s daily and weekly lifestyle rituals are critical to the development of disease in the first place.
Hippocrates said “no disease caused by food should be treated by any other means”. He would be appalled with the practice of modern medicine and its preoccupation with expensive pharmacological treatments for largely preventable diseases such as obesity, diabetes, metabolic syndrome, cardiovascular, and neurodegenerative disease. Each time OHIP removes a previously insured service, I consider how that service can be added to the Deerfields menu of services so that patients who value FaceTime with their physician and having all of their issues addressed at a single visit, can get the care they need and deserve. This is not private medicine. This is good medicine.