Viewpoint: The downfall of the clinician-patient relationship 



By Mary Dudzik, M.D. 

I read Jill Goldthwait’s column in last week’s paper with a combination of sadness and relief that someone is talking about the loss of humanity in health care. I was particularly struck by the last two lines, “We want our health care providers to have time to see us, to hear us. We want them to have time to care.”  

Believe me, health care clinicians want the same thing. I use the word clinicians to encompass doctors, physician assistants and nurse practitioners, as many of us do not like being called “providers.” 

This June will mark 30 years since I finished my family practice residency in Bangor. I will be forever grateful that I spent the first 20-plus years doing what I trained for, doing what I loved, practicing full spectrum family practice. I was able to see all ages, see people in the ER and in the hospital, see people in the office, deliver babies and take care of them as they grew, and see people in nursing homes. Seeing people in every one of those places, when they were at their most vulnerable, was how that “personal, even intimate” relationship that Ms. Goldthwait references evolved.  

But slowly and insidiously, health care has gone from being a service that I was proud to be a part of to a corporate business that I am embarrassed by. At every turn, it is almost impossible to take care of patients the way we used to, the way we want to. I no longer see patients in the hospital because most hospitals want their inpatients taken care of by hospitalists, clinicians who see only hospital patients and have no connection to them otherwise. I respect hospitalists and the work they do, but I will always feel that patients would rather see their trusted family doctor when they are sick, and not a stranger. In addition, the administrative burden of seeing a patient, whether in the hospital or the clinic, has gotten out of hand. I used to be able to see a few hospital patients, as well as a new mother and baby, before going to the office. Now there is simply not enough time, mostly because of electronic medical records and the enormous amount of time and attention they take away from patient care. 

It is hard to point a finger at any one thing as being the one thing that has poisoned medicine, but the electronic medical record (EMR) is certainly in the running. Don’t get me wrong, there are some things about it that are great. For instance, I love being able to electronically send medication refills to the pharmacy with the click of a button. However, the records of the EMR are no longer a simple note of what was discussed, what was done, and the action taken by both patient and clinician, which is what they used to be. It is rather a complex billing document that is reviewed by insurance companies who do not care even a little bit about the type and appropriateness of care given. It is often hard to go through notes to find the information that is needed to take care of a patient because it is obscured by unneeded, irrelevant information. But unless this information is included, unless specific phrases are used, unless specific boxes are checked, payment to the health care organization/clinician will be reduced or not paid at all.  

EMRs have also completely distorted the clinician-patient relationship. Pre-EMR, records were in paper charts. The only information in them was medical, no billing information or busy work. They were not perfect, but it was much easier to sit with a chart and flip through it and maintain eye contact with a patient. With EMRs, there is a temptation to stand in front of the screen and look at it while talking to a patient. I can honestly say I don’t do that. The main reason is not because of the distraction of the EMR, it is because I know I will learn more about a person by looking at them and talking to them than I will from a screen.  

I understand the temptation for a clinician to look at the computer and type into it during a visit. Those folks are trying to protect their time off, which is a vanishing thing. People have no idea how much time EMRs have added to our days. It is estimated that for every hour we spend in face-to-face care with patients, we spend two hours in the EMR documenting the visit, fulfilling requirements, billing and other administrative tasks. I think that is accurate. Clinicians spend hours before and after work doing this data entry, this busy work, that for the most part has nothing to do with patient care. And most of us get paid only for the hours we see patients.  

So what are the solutions? As we know, there are things that medical offices can do, and some already do, to try to provide patients with a personal service as opposed to a business transaction. I am fortunate to work in an office with four 50-plus-year-old clinicians and one 20-something who value the clinician-patient relationship as I do. Every day we look at our schedules and if someone is seeing one of my patients and I am seeing one of hers, we simply trade (after confirming it is OK with the patient) to foster continuity and an ongoing relationship. We see if and where in the schedule there is room to squeeze in a patient who needs to be seen that day. We do the best we can, but we cannot always do it all.  

I also think that a single-payer/Medicare-for-All system would greatly improve the lives of patients and all who care for them. There is no reason for health care to be tied to employment. It is a human right and should be afforded to all. The number of people I see who have put off medical care until age 65 because they could not afford it is appalling. By the time they show up for that first Medicare exam, their diabetes has already caused kidney damage, their cancer has already progressed. Let alone the countless others who never made it to 65. A single system, if done right, would allow that money put into it would go to patient care and to the organizations and people who do that care instead of numerous insurance agencies whose CEOs make millions of dollars every year, who each have everchanging rules about what they will and won’t (mostly won’t) cover that we have to try to stay on top of, whose prime directive is to ensure profits for their shareholders, not secure the health of a population. 

Health care was never meant to be a for-profit business. It was meant to be a service to all. What we are doing is not sustainable. This country spends more on health care than any other nation and has the worst outcomes. Time for a change. Our lives depend on it. 

 

Dr. Mary Dudzik is a family practice physician from Bar Harbor.

 

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