Before Johannes Gutenberg invented the printing press in 1450, books in Europe were copied by hand, mostly by monks and clergy. Ironically, they were often called scribes, the same word we now use for the new class of healthcare workers employed to improve the efficiency of physician documentation.
Think about that for a moment: American doctors are employing almost medieval methods in what is supposed to be the era of computers. Why aren’t we using AI for documentation?
The pathetically cumbersome methods of documentation available (required) for our clinical encounters is only one of several antiquated presumptions in American healthcare. Other inefficiencies, often viewed as axioms, especially in primary care, make the trade I am in chock full of time wasters.
Whereas in most other “industries”, people talk about reach, scale, leverage and automation, primary care is still doing things one patient at a time. The automation in our field is not one where processes happen without human involvement according to preset patterns. Instead, it is an ongoing effort to make medical providers behave in automatic fashion with patients on a one-on-one, one visit at a time basis. The value of one-on-one is when you individualize, give unique advice considering multiple individual parameters; saying “in your particular case”, rather than “everybody should eat a healthy diet”.
Primary care here is wasting time in many ways:
When health maintenance and disease prevention is done by physicians. I keep writing about this, but a standing order to offer pneumonia or shingles shots, diabetes or lung cancer screenings and so many other things to people over a certain age or with certain risk factors can be handled by non-physicians. This would keep the six figure problem solvers doing what only they can do. It would also (a not-so-wild guess) probably double physician productivity.
When we are forced to act as if we only see our patients once – ever, instead of over several visits year in and year out. We can’t see you quickly for your sore throat or UTI, because a visit without the required screenings hurts our quality ratings. Having non-physicians do the screening (the point I am making above) is not necessarily the solution because my medical assistant can’t keep me humming and at the same time do all the screening duties on even patients with the simplest of clinical problems.
When we keep thinking that the only time and place for us to interact with our patients is in the office visit. All other “businesses” are figuring out how to engage their “customers” via emails, podcasts, events and so on. Very few medical practices are doing the same. We typically only make money when patients are seen in the office, but if we could have staff interact with patients in whichever way is most appropriate between visits, the time patients spend in the office would be shorter and more effective and clinic productivity would improve – as would quality. Right now, so many of our visits are a real scramble to get through.
When we use the telephone in such inefficient ways. In an era when people generally have their personal cell phone on them, we act as if we are calling them at the phone booth on the corner of their block. They leave a message saying “please call me back”. You do and they don’t answer. You leave a message saying “please call me back”, and so it goes. A personal cell phone is as private these days as an email or a secure patient portal. I think we can leave general messages with patient permission – your tests came back normal, please double up on your new prescription and come back in two weeks, things like that.
When our administrators are too preoccupied with well-meaning but stilted and bureaucratic top-down mandates. Just like providers often can’t be as helpful as they would like to their patients because of our mandates, there is little room for innovation on the administrative side because of the regulatory burden.
We have become a terribly rigid and stuffy “industry” during my 40 years as a physician. We are not like a flea market or Saville Row (London’s bespoke tailor street) like yesterday’s private practice. We are like the postal service or the US immigration service. There will be disruptions if we don’t start moving with the times, and with our patients. They will move away from us whenever they can, to Concierge Medicine, Direct Primary Care, freestanding clinics, varyingly alternative practices or even non-medical caregivers, leaving only the most utterly sick and complex patients with us. Is that what the Fed, Medicare, Medicaid and the insurance companies want for us? And is that what is best for most patients?
A Country Doctor Writes: 
This is so true! I love working in Direct Primary Care, visits are focused on what the patient needs and then they are much more willing to come back for the routine screening and follow up. We leverage technology in ways that are not captured by traditional insurance based healthcare practices. These interactions mean we are meeting the patients when and where they need it, saving time and money. This fulfillment for both patients and providers gives meaning and reward to my work. Thank you for your blog, good read.
This is the best article you’ve written yet! Bravo! You really captured the nonsense of using big business automation approaches to an individual art and science practice. Visits were so much more productive when I had paper charts! I still refuse to use any commercial EHR. I developed my own. Part of my work now is performing disability evaluations, and as such, I review a lot of medical records and they are all crap – so little real information about the person/patient!
“Is that what the Fed, Medicare, Medicaid and the insurance companies want for us?”
It’s certainly what the AAFP wants for us. They’ve aggressively supported every miserable policy you correctly rail against.
I have 47 years of medical practice and I can’t say I disagree. The one issue is when the lawyer says to you, after the patient has a serious reaction to a shot….”did you even lay eyes on the patient, Check a heart beat or pulse to see if there was nothing else going on? And when I say “No” they bring out the cross and nails.
I had planned to practice until I passed on, like my father. But medicine is no longer the calling I responded to. I’m just a low level government employee (decently paid, however) in a government where meeting criteria is more important than treating patients. I will be retiring shortly.
Big city physicians are not held to the same standard of care as those in a smaller community! Think about it when you live in a smaller community you live in the neighborhood of your relatives, your friends and your patients! My god you better perform and by god you better be there for them and by god you better deliver the best medical care you can! Don’t pass it off wannabes like PAs and or others like nurse practitioners. Be a doctor first and act like one!
“Wannabes like PAs and or nurse practitioners” – wanna be what??
Wanna bes???? Mid level providers are more preferred now by patients because we listen, care and provide quality service more than Physicians. We have better bedside manner (FACT). Researchers used the U.S. Agency for Healthcare Research and Quality’s Consumer Assessment of Healthcare Providers and Systems (CAHPS) questionnaire. Of the 18 core questions, NPs had better scores than physicians on 15, according to The Clinical Advisor. “ In general, the findings indicated that NPs spend more time with patients, listen more closely, provide more feedback, show more respect for patients’ opinions, and the like. Note: Researchers point out that physicians scored well on the survey–an average global score of 7.2 out of 10. In comparison, however, NPs earned an global average of 9.8.”.
Mid level providers are not wanna bes. You’re “old school opinion” belongs to the past. We are educated and trained by your fellow physicians. We do continuing education to updated our knowledge. A wanna be is when you’re a provider yet you act like you’re not.
“wannabes”? Shame on you. Careful, Dr. Morgan. Your ignorance is showing-don’t let your relatives, friends or your patients see that!
all this is so true i am glad i am old and out of medicine…retired from family medicine last year and it has gor worse…..no wonder no one wants to do this job and when you talk to other specialists they as well say PC is now the hardest job in medicine……it is mindnumbingly boring…..i miss the patients and thats it.
When I was in private solo practice in rural Oklahoma, I saw 20-30 patients per day, writing 4-line SOAP notes. I did office skin surgeries, pulmonary function testing, EKG’s too. My office assistant (medical assistant) had no degree beyond high school and had no certification—I trained her myself. Outcomes were about the same as now except for improvements in diagnosis and treatment that have developed since. QA has always been only about documentation, not outcomes. The system is still process-oriented, not outcome-oriented. We generate much longer notes and take much more time, but that is all. In out single-payer system (VA), NP’s and PA’ do most of the routine primary care—the protocol-driven stuff, with us physicians doing those patients that “don’t fit. One would think that this would be more efficient, but with all the mandated data entry and screening, we are still pressed in we see 6-8:day due to the administrative:documentation burden.
Amen
If we do not come to grips with this, today’s decision makers ( administrators) wil fill that void. I seriously doubt that this will result in improvement. WE ( emphasis on the inclusive we-admin and providers in the trenches and patients) must collaborate to achieve improvement.
I was with Max G. Morgan, MD, until his last part, “Don’t pass it off [on] wannabes like PAs and or others like nurse practitioners.” As a primary care PA for 40 years, I have never thought of myself as a “wannabe” or tried to pass myself off as a physician. We all have our strengths and weaknesses, and I enjoy working within a team, with doctors, PAs, NPs, nurses, medical assistants, pharmacists, psychologists, social workers and dentists, Working long and hard on difficult patients, having to deal with horrible electronic medical record systems and poor administrative support processes, at lower salaries & benefits than our physician specialist colleagues… Wannabes? Really?!
The everpresent regulation with computer data entry now acting as “Big Brother” watching every detail has made PC medicine a game of selling data with whoever has the fastest most efficient computer the winner. Patient care of real patients actually gets in the way of such efficiency and those patients with dementia or multiple problems simply become obstacles which many mercenary practices would rather shed their panels of. Such perverse incentives drove me from private practice to locums and eventual early retirement. Until payers figure out how decrease their demand for evermore data and involve patients in rewarding true service I have little hope for any return to the old glory days of private practice. Many aspects of data collection and decision making will likely be offloaded to computer, to be supervised by less cotly midlevels on a fragmented care basis involving far more visits for multiple issues that used to be covered under one visit. The big players have already created their systems for this, but such care still has yet to figure out how the old style FP, who could efficiently know the true needs of the patient, is to fit in to such a system. And I, as an electrical engineer turned FP, actually looked forward to computertized records, only to conclude that the changes they wrought have hindered the efficient delivery of care and turned it over to a large bureaucracy with all the attendant inefficiencies. Perhaps paying the FP by how many procedures, visits, and tests he saved would help, but HMOs tried that 30 years ago and that was rejected, so I guess we have to keep seaching.
As a Family Nurse Practitioner in a FQHC in the suburbs of Chicago, I agree with every argument in this article as well as the comments by many of the other providers. I see 20-28 patients in a day many of whom have uncontrolled diabetes and hypertension. Efficiency is key and the current methods available for efficiency are lacking and make an impact in the care we provide unfortunately. However, my Chief sends me patients who she has a difficult time managing as she knows I am a well-equipped provider with great success managing diabetes in a population that almost always refuses insulin. I do not see myself or my colleagues as “wanna-be’s” and this is disparaging to read a comment like that in a global pandemic where each of us should be supporting and encouraging our colleagues who are struggling to care for people in unprecedented times.
I would like to add one other thing As someone who has had to deal with a licensure board (MS), the board feels you should not and can not be friends with those in your community or reachable, approachable. So how does one practice in a rural setting? Article is spot on and so much more. The almighty $ is the only thing that matters. It’s like being a salesman, ‘what have you done for me lately’ as the corporations for their shareholders only want.
For preventative services, I think we should empower patients to be aware and be proactive about the recommended screenings and other preventive actions such as vaccines. They could receive an automated message: You are due for a colonoscopy, find out more “here”… Request a colonoscopy “here” and a provider would review request and approve it.
I share the author’s frustration with the EMR and what it mandates. I personally think the reason these are forced upon us in primary care is that powerful people are making so much money off the EMR. It’s always all about the Benjamins! EMR was sold to us as something that would improve patient care, but seems to just get worse and worse.