OP-ED

The Cost of Fear

I was talking to a fellow physician about a mutual patient. I had
information  that would help him in their  care and he was taking the
unusual step of asking me for my information.  I was impressed.

“Could you fax me those documents?” he asked.  ”Here’s my fax number.”

I scrambled to get a pen to write down his number.  Then I had a
thought: “I could email you those documents much easier.  Do you have
an email address?”

Silence.

After a long pause, he hesitantly responded, “I would rather you just fax it.”  He said no more.

This is a typical reaction I get from my colleagues when suggest
using the new-fangled communication tool called email.  The palms
sweat, the speech stumbles, and the awkwardness is thick in the air.
It’s as if I am suggesting they join me in an evil conspiracy, or as
if I am asking them to join my technology nerd cult.  There is a
culture of fear in our healthcare system; it’s a wall against change, a
current of stubbornness, a root of suspicion that looks at anything
from the outside as a danger.  Instead of embracing technology, doctors
see it as a tool in the hands of others intent on controlling them.
They see it as a collar on their neck that they only wear because
others are stronger than them.

It’s the only reason I can see for the resistance of a transforming
technology.  It’s the only way to explain how they would favor a
non-system that hurts their patients over a system that can improve
their care immensely.  After all, what good is it to embrace a
technology – no matter how good – if it will take away their ability to
practice medicine?  ”It’s good for you!” they hear from politicians and
academics, but they see it as a poison pill.

What gives me cause to use such strong words?  Surely it’s not that bad!
It is, and what makes me so sure of it is the very high cost of their
resistance.  The cost of this fear is huge, and so the fear itself must
be bigger for a healer to accept that cost.  What is the cost?

Frustration

We see our patients without information.  The call from the
specialist I described at the start of this post was a truly rare
event.  Most of my consultants don’t expect to get information from me,
and I expect to work without their input.  All of this has happened
despite my repeated attempts to improve our system.

  • I have offered to send our referrals with attached appropriate documents.  I can do this very efficiently using email.
  • I have tried to send labs, x-rays, and other information to
    specialists when I felt they couldn’t do their job well without them.
  • I have requested that they stop mailing their information to me, instead faxing them to our server.
  • I have offered our hospitalist physicians after-hours access to our records for our patients.

Ironically, the only physician who has embraced my offer is an ENT
at our local teaching hospital who specializes in parathyroid surgery.
I shoot him an informal email when I have a suspect calcium level and
within the day I get a response.  In exchange, he gets consults with a
full set of labs and can practice with greater efficiency.  He also
sends me quick notes on my patients when he sees them, asking me
questions to fill any gaps.

Cost

The total lack of communication results in huge cost to our system.
It’s not that the communication tools are not there, it’s that they
just are not used anywhere near where they should.  Examples?

  • A woman came to my office recently after being hospitalized.  I
    never was notified of her hospitalization, only finding out when she
    came for a “hospital follow-up” visit.  While in the hospital, she was
    found to be anemic and so had a workup for this condition.  This workup
    included a full consult by a hematologist and a gastroenterologist.  If
    my records had been looked at, they would have noticed that I did a
    workup 6 months earlier for her anemia.
  • Specialists not accepting email copies of the labs I run usually
    end up repeating the tests.  For specialists like rheumatology – where
    the diagnosis is largely made on the basis of those labs – this
    elevates the cost by several thousands of dollars.
  • I have had patients rebuffed by consultants who “didn’t know why I
    sent them.”  Nobody calls, and nobody accepts email.  I could send them
    whatever information they need in a matter of minutes if they would
    accept email.  Heck, they could even text me if they wanted.

The real cost, of course, is to the patient.  The Hippocratic oath
says we should “first do no harm” as physicians.  Yet our non-system of
communication does just that, and even kills people.

So why would presumably smart people reject a technology that could
improve care, reduce cost, and reduce frustration?  Did any of them
order gifts from Amazon?  Do any of them bank online?  I am sure they
do, and they do so because it makes things easier and more convenient.
So why does that ease and convenience not apply in medicine, which is
far more broken than shopping or banking ever was?  It’s not fear of
technology.

To be honest, I don’t really know.  My best guess is that it is the
overwhelming sense of pessimism most doctors feel about their
profession.  Docs are second-guessed by lawyers, patients, TV shows,
insurance companies, and the government.  The fate of medicine is not
in the hands of doctors, it is in the hands of politicians, corporate
executives, and malpractice attorneys.  It seems to me that the only
way to avoid more scrutiny and to hang on to some control is to hold
tightly to what we’ve got: our information.  Once that information is
on computers it is far more accessible by others, and this is a bad
thing if the goal is to retain full control.

So are docs just power hungry, wanting total control because of
their inflated egos?  Some are, but most are not.  Even the most
technologically-minded of us, however, have an increasing unease about
the intrusion of others on our ability to do our job.  I don’t want to
be thinking about attorneys when I am prescribing medications.  I don’t
want to withhold information important from the chart because I know
patients will be reading it.  I don’t want to be forced to include a
lengthy justification of a procedure in my notes to make the insurance
company happy.  As it stands, it sometimes feels like anything we
include in our records “can and will be used against us.”

If someone like me, a physician who embraces technology, feels
increasingly penned in by the increasing number of people peering at
what I do, it is very understandable that other physicians reject
technology outright.  They’ll quit before they give up their
independence.

Is it stupid?  In some ways it is.  It certainly is a rejection of
the centrality of what’s good for the patient.  But our system can’t
afford to alienate physicians at this time.  If technology is going to
be pushed, there needs to be a reassurance that this won’t be used
against them.  I am frustrated at the lack of  acceptance of
technology, but even more frustrated at a system that is hostile that
forces docs into this foxhole.

ROB LAMBERTS is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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doxycyclineArthur Williams, MDhandbags wholesaleTiffany Matthewstexas health insurance Recent comment authors
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doxycycline
Guest

communicate with each other. The national directory of physicians meant that we could quickly send to any physician, without having to know their fax or email. Like an online email system, recipients can reply and forward messages, so now we could get immediate feedback from colleagues in other locations, and in important cases, have a real dialog about patient care. The “Group Discussions” feature allows the specialist in town, the hospitalist, and the PCP to all join in an online dialog about one patient. The application works well on our smartphones. When our group wanted to send documents on our… Read more »

Arthur Williams, MD
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Arthur Williams, MD

My partner and I head two hospitalists groups in the Boston area, one acute care, the other a rehab hospital. For years our handoff communications went through paper mail or fax. We were very diligent about communication. Even so, specialist from acute care settings and primary care physicians in the community complained that our group was like a black box – that they were not getting good communication about the care we were providing. The hospital even setup a physician portal so that any on-staff doctor could log in remotely and access their patient’s information. But this “pull” model never… Read more »

handbags wholesale
Guest

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Tiffany Matthews
Guest

After having worked in hospitals and nursing homes, I do not think there is such a thing as “privacy.” HIPAA violations are a reality in everyday health care.
The need to streamline processes is a necessary concept. But how do we do this and give complete privacy to patients before we actually address what they are saying in an elevator?

texas health insurance
Guest

It’s understandable that doctors, who are subject to intense scrutiny, would be wary of sharing valued information. But if that information can help doctors better provide their services, then the end result would likely be a reduction of said scrutiny.

Rob Lamberts
Guest

Vikram: Agree 100%. The problem is that in a PCP office there are not big enough margins to allow reinvestment or to wait for a slower return. Our office has a huge advantage because of a good implementation. But there is nearly no motivation for there to be communication b/w providers as it is not made easy by any system. Our system penalizes those who spend extra time by not paying them more to do so. Why communicate when it reduces your revenue? We do, but only because it is very simple with our IT. You can’t send email, however,… Read more »

Vikram C
Guest
Vikram C

Would it help if insurance pays doctor/office per email correspondance with patient via insurance email and if patient is satisfied clicking ‘OK’ on the satisfaction button lead to small payment to doctor’s office? There is definitely a cost of entering data into computer. But I have seen work arounds, doctors speaking up notes to dictatophones and then someone else in office types it up. Or how about interns, trainess, nurses etc taking notes. or how about doctors learning to use ViaVoice for voice recognition so that notes can be taken easily. However data entry by doctor is all about that… Read more »

James
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James

I used to get medical records mistakenly sent to my home fax number, which was one digit off from a doctor’s office. It happened even after I notified the sender. A couple of days ago I found a piece of snail mail lying in the road from Medicaid to a client. It was unopened and likely contained personally identifiable health information of some kind. The street near where I work has a pharmacy. I have found the bags from filled prescriptions — still with all of the patient information attached — blowing down the sidewalk. These included prescriptions for narcotics… Read more »

bev M.D.
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bev M.D.

My guess is that iknow isn’t taking the time to know much about his patients.

Rob Lamberts
Guest

exhaustedMD has made my point eloquently (albeit ironically). That’s the prevailing attitude. Thanks. Square on, Margalit. Exactly my thoughts. Most people have a hard time doing something with someone looking over their shoulder. Docs (including myself) feel increasingly that this is the future of medicine: to practice with the world looking over our shoulder. Propensity: huh? I assume I am capable because I read my email? Perhaps you should read the post. I am defending the reluctance of docs, not attacking it. I do think that it’s a mistake to forego a communication tool that improves quality (which it can),… Read more »

propensity
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propensity

Your notion that email for the patient centered physician is seriously flawed. Do you sit in front of the computer or the patient? Has the computer become your patient? Do you read all documents and medical literature on the screen? I suppose you assume yourself to be a capable physician because you use email. Email might be efficient for you as its chearleader but for most of us who actually care for complex patient care problems, email is a slow and inefficient mode of communicating complex thoughts. The EMR that loads up on billing associated gibberish saps an equal block… Read more »

Margalit Gur-Arie
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Margalit Gur-Arie

I would like to address the last part of the post. Most of the privacy discussions center on patient data and it is by and large extremely important, but few ever mention physician privacy. Does the patient, or other providers for that matter, really have a right to everything that normally goes into a chart? There may be informal notes that a physician writes in a chart that he/she may not wish to share. Maybe some side notes that could be offensive to the patient or outright dangerous. I’m not talking about factual information such as diagnoses, test results, medications,… Read more »

ExhaustedMD
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ExhaustedMD

God, how many times in the history of our species do we hear this basic refrain of “oh, this innovation/application/improvement will make life easier and free us from the confines of a tedious, banal existence!” Hey, last I checked, we still take less vacation time, work more hours, and have more diseases than other Western world cultures who don’t have a cell phone in every citizens’ pocket, 2 or more flat screen TVs in most homes, 1 computer to every 1.5 people in the vacinity, and an average of 3 or more prescriptions per every adult citizen over 18 years… Read more »

Rob Lamberts
Guest

What I am doing is taking my personal experience as a practicing PCP in a private practice (for past 15 years) and IT “expert” (our practice has been nationally recognized for use of IT and I have lectured on application in small practice settings). My perspective is exactly that – a perspective. I understand it does not apply in all situations, but our setting is highly motivated for efficiency as it is almost entirely composed of for-profit practices. What that means is that efficiency is rewarded financially. Why would doctors turn away from efficiency and hence increased income? Having fought… Read more »

iknow
Guest
iknow

What is efficient for you is not efficent for the doctors who are on the move and can not sit tethered to the devices. The devices interfere with the complex efficient multitasking that is second nature to the doctors who refuse to sit and click. Sorry. You got it all wrong.