Health 2.0

Why I Don’t Accept E-mail From Patients

Dr. Wes (a cardiology blogger who all should read) wrote a very compelling post about technology and the bondage it can create for doctors.:

The devaluation of doctors’ time continues unabated.

As we move into our new era of health care delivery with millions more needing physician time (and other health care provider’s time, for that matter) – we’re seeing a powerful force emerge – a subtle marketing of limitless physician availability facilitated by the advance of the electronic medical record, social media, and smart phones.

Doctors, you see, must be always present, always available, always giving

This sounds like dire words, but the degree to which it has resonated around the web among doctors is telling.  He continues:

Increasingly the question becomes – if we choose future doctors on their willingness to sacrifice for others without expectation of appropriate boundaries and compensation – will we be drawing from the same pool of people as the ones who will make the best technically-skilled clinicians? What type of person will enter medicine if they know that their personal life will always take second place to patient care?

Dr. Brian V (long last name, but another one who you all should read) adds his voice to this:

It started with the pager and it’s evolved to real-time social media.

I’ve seen it too many times:  Physicians excited to please open the door to unlimited patient email only to see themselves shutting their families out at night as they answer questions – all for free.  And those physicians who suggest that emails should carry a fee are indicted for greed.

We have been on EMR for 14 years, yet we don’t accept email from our patients.  We could do it, but we don’t – and both of these doctors hit on the head the reason why we don’t.  The goal of IT in our office can be summed up in one word: efficiency. The practice of medicine has become dominated with non-clinical tasks.

  • We have to gather information and organize it.
  • We have to serve as an “information central” for our patients, collecting from disparate sources to make informed choices.
  • We have to comply with the maze of government and insurance industry rules.
  • We have to give information to patients and to other medical providers.

So what actually happens in our office is less medicine and more information management.  IT allows us to do this in less time, leaving more time for our patients.

Accepting emails from patients at this point would mean more time spent doing un-reimbursed tasks.  Actually, it would potentially decrease our revenue, handling problems outside of the office (for free) instead of being paid for our services.  Doing so would give us three options:

  1. Working extra hours to make up for lost revenue.
  2. Giving free care via email and just accepting less pay, seeing less patients total.
  3. Spending less time with each patient to make up for the decreased revenue.

I am busy enough that I don’t want anyone to have to come in for things I could handle remotely.  Email communication with patients sounds ideal in many ways.  But unfortunately, the business case for this is so bad that we can’t open ourselves up to patient emails.  One answer would be to have a minimal charge for an e-visit ($20?), which would be credited toward an office visit if the e-visit warranted that the person come in to be seen.  The amount needs to be enough to ward off frivolous questions, and would have to be applicable to ALL insurances (including Medicare and Medicaid).

Email also works well with the idea of the “medical home,” which reimburses doctors for overall care of populations.  (I give my opinion on the medical home in this post.)

Until this happens – until we are somehow paid for giving care outside of the office – this useful technology will remain unused.  Is it greedy to not want to give things away for free?  Is it greedy for me to not want to spend less time with my family, make less money, or spend less time with patients?  Is it greedy to think I am worth $20?

If so, you can call me greedy.

Rob Lamberts, MD, 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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imdocCK SudpExhaustedMDTed Recent comment authors
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CK Sud
Guest

Go ahead. Charge – I believe good things in lide needs to be paid for. And hire an intern to screen emails and respond accordingly.
because heal is an issue that does not follow a clock. i would prefer to write to my family doctor, who knows my history, to respond with a suggestion or referrral instead of standing in ER and being checked by an unknown doctor.

imdoc
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imdoc

” And hire an intern to screen emails and respond accordingly.” At a minimum it would have to be the office nurse as is done with phone calls now. The problem is it takes a well trained person to get all the history points just to make a good judgment about disposition. So, the costs remain since a staff member must get paid and then there is no revenue against that. Insurance contracts and public plans prohibit payment for anything but a face to face visit, reinforced by the arcane coding system which requires an exam component. I expect telemedicine… Read more »

p
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p

I would have no problem paying the 20 dollar fee out of pocket for being able to report symptoms and rationales and getting a test ordered before my visit thus avoiding the second visit to review the test resulting from reporting this information and saving trips and time and delay in treatment. . .it’s what a co-pay costs anyway!

ExhaustedMD
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ExhaustedMD

Didn’t take long for the validation, re: how the government is planning to make emailing a forced practice: “And what many believe to be an outdated reimbursement system–one that drives doctors to schedule office visits when a phone call or email might do–doesn’t help” Ok, but based on who’s judgment? Isn’t that the doctors’, pardon the pun, call? http://www.usatoday.com front page story today, I can only wait to read the health deform advocates’ take on this. Oh, go to page two if you read a paper (you know, that material you line your bird cage with, to wipe your windows… Read more »

ExhaustedMD
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ExhaustedMD

I don’t think you answered my question. Do you believe in a for profit model to drive health care, or not? And if you do, how do you really provide good care when you are simultaneously watching your wallet? Not that I think you personally do this. But, I think our colleagues have bought into this bs that we should be making a killing. Literally!

Rob
Guest

Exhausted: The only way it can be a for-profit business model is if we can post our prices up-front and compete based on quality and cost. The hidden nature of the cost of HC is what makes it so damn complicated and frustrating. It’s what makes people not trust us. Why should hospitals charge $10 for 1 pill of Tylenol? Why should there be hemorrhoid cream that costs $100?? Why don’t doctors ever tell you what they will charge for a visit? The system prevents/enables this, and makes us targets of mistrust. Add to it docs who do gouge the… Read more »

ExhaustedMD
Guest
ExhaustedMD

My mistake for giving a damn. Just hope the people who visit this site find what they want. It won’t be enough from a computer though. When we stop getting enough satisfaction from genuine, supportive, sympathetic human contact, all will be lost.
Good luck America. you need it, you just won’t be getting it from these people in DC.

Ted
Guest
Ted

I will do emails when i am paid for them. Period. Just like a lawyer or CPA.

twa
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twa

So let me see if I “get it”. You spent 12+ years in advanced schooling, endured rigorous and exhausting training, spend every waking minute with the specter of having someone’s life in your hands at a moments notice, carry a pager and a cell phone constantly which can go off at any time with anything from a nit to a traumatic situation, work 80 hours a week, plus weekends, etc. But it’s “just a job”. It’s just a way to make a living. And your patients are not customers; they are just people you interact with in order to get… Read more »

ExhaustedMD
Guest
ExhaustedMD

Dr Lamberts:
Do you believe that health care should accept this enforced belief it operates under a business model, that as a basic premise there should be a profit driven expectation to the services in the end?
I honestly am interested in your opinion.
Sincerely,
ExhaustedMD

Joe
Guest
Joe

Fee-for-service is clearly corrupting American medicine and bankrupting ordinary Americans to the financial benefit of medical professionals. Maybe Dr. Lamberts should get a salaried job working for the VA or one of the high quality, low cost “Clinics”. Then he would find out that us poor salaried workers never get paid extra for working extra hours.
Dr. Lamberts, do you charge your patients half as much for a 10 minute visit as for a 20 minute one? I didn’t think so.

ciphertext
Guest
ciphertext

Medicine in the U.S. is a business, as it should be. There is no reason why a practice should not be allowed to decide whether or not to “charge for email access to the practice” in the same manner that they are allowed to charge for other forms of access (office visit, phone call, etc…) to the practice. That is a business decision to be made by a practice on a case-by-case basis. Some practices may wish to include the ability to contact your physician via email in their business model, maybe it would be a good “selling point” or… Read more »

ExhaustedMD
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ExhaustedMD

By the way, my Animal House comment was related to the John Belushi character saying “8 years of college down the drain”, making the reference he was a career student. I was not inferring that graduate students are the bums of that fraternity house. But, I do take issue with the rationalizing that it is no big deal for people to finish graduate training in more than 10 years including their college years. When you make that kind of committment to that educational demand, it takes true exceptional situations to put post graduate training on hold. I read the above… Read more »

ExhaustedMD
Guest
ExhaustedMD

you truly do not “get” it, Paolo. Carrying a pager to come to the lab, call a colleague, even for a vet to come to treat a sick animal, is not the same as getting paged to potentially try to problem solve a life crisis for a human on the phone. I have learned that until you carry a pager or be on call to handle life emergencies, or at the very least be called for alleged emergencies to only have to tell the patient or family to follow up in the office within the next 24 hours, you have… Read more »

Paolo
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Paolo

Dr. E., I don’t know where you get your stereotypes from, but I can assure you that the typical assistant professor at Harvard or MIT does not get there by living the “animal house” life or having little commitment to finishing what they start. These are people who have worked 80 hour weeks to get through an average of six years of grad school and several years of post-doc. And they typically make less than 100k salaries. And yes, patients are customers. If they don’t like what they see, they can go elsewhere, and they often do. I have used… Read more »

Margalit Gur-Arie
Guest

Dr. E, very few people work 40 hours weeks nowadays. Sure some PhD folks may be slacking, but those in sciences and engineering are working their proverbial butts off and it still can take 8 years. No, they do not have responsibility for people’s lives, but that’s no reason to dismiss their efforts. I don’t know what it is that you are protesting exactly, but I have a feeling it is the, so called, health care reform. Let me ask you a very simple question: in view of all the upheavals in health care right now and in view of… Read more »