I’m a semi-retired cardiologist. I currently volunteer at a free community health clinic for individuals who do not have health insurance. Many of these individuals are undocumented foreign workers, yet we care for them seamlessly, without the restraints of our bureaucratic billing system and the burdens and restrictions promoted by the insurance industry.
As I age, to my chagrin and utter dismay, I have also unfortunately become a patient. I have dealt with and continue to deal with certain significant health challenges. What I have witnessed and experienced as a patient is both disappointing, frustrating, and truth be told, alarming.
As a practicing physician, and until I also became a health care consumer, I was never aware of all the roadblocks patients encounter to simply make an appointment. I admit I am spoiled. If I had a personal medical question or concern during my active practice days in the hospital, I’d simply ask a colleague in the halls or in the doctor’s lounge, and we’d address it promptly, usually with the caveat of “come up and see me in the office this afternoon.” That privilege is long gone but has clearly jaundiced my view of physician accessibility.
There is obviously a serious physician shortage currently since it is virtually impossible to see any specialist (or primary care physician for that matter) in a reasonable time frame. More often than not, the next available appointment is usually several months away.
When I was practicing, if a referring physician called and asked me to see a complex, potentially unstable patient, I would work them into my schedule within a day or so. No more. If you’re lucky, they might move you up to a 4–6 week time frame rather than the original 4–6 months. Hopefully, you remain reasonably healthy, and nothing bad happens during this extended waiting period.
Once you’re finally seen, you are generally screened by a medical assistant prior to seeing the physician. The assistant asks the exact same questions you previously spent an hour painfully filling out on the digital portal.
Most alarming is the fact that no one does a physical exam anymore. A thorough exam is—or was—one of the key tenets of my medical school education. Apparently, it is a lost art. I guess it is easier for current-day physicians to simply order a battery of tests.
And there is actually no pretense of even doing an exam. I’ve started to notice most physicians don’t even carry a stethoscope. In medical school, we were taught this was perhaps our most valued tool. Now it’s an afterthought at best. I’ve had to be proactive and actually ask an infectious disease specialist to inspect my surgical wound rather than just checking the cultures when I was battling a postoperative infection. I had to ask the primary care doctor to listen to my lungs rather than just look at the X-rays when I was short of breath, demand the urologist perform a prostate exam rather than just referring to the PSA, and almost beg an orthopedic surgeon to perform a thorough musculoskeletal and neurological exam when I was dealing with hip and back pain rather than just reviewing the MRI and CT scans.
We are witnessing a very disturbing trend where physicians are treating the lab tests and/or acquired images and not the patient’s clinical situation. When they rely on all these tests, they lose sight of their true mission, which is to treat the individual. Everyone is different. Everyone has different pain thresholds. Everyone has a different level of baseline activity that they hope to return to. Everyone has different social and financial support systems. Each of us must be treated as separate and unique individuals.
Many physicians simply click on the “normal” template in the electronic medical record for the exam without actually performing one. On a very basic level, this is fraud. On another more concerning level, this is counterintuitive to the practice of good, sound medicine. How can the physician follow your muscle strength or range of motion or the intensity of your heart murmur or lung sounds on serial exams if one has never been done appropriately in the first place? This is a very dangerous precedent that will lead to serious harm and untold consequences.
If you have the knowledge and courage to find the “after visit summary” (on the portal, after a lengthy search), you can easily surmise that the physician has used a template for the patient history section as well. There are no quotes, no mention of your actual words and concerns, just another cut-and-dry template.
These offenses are compounded by the physician looking at their computer rather than at you, the patient, during your visit. The lack of eye contact is beyond disturbing. It creates a major barrier to the interaction. It is impossible to develop confidence, establish rapport, and stay engaged when one party is solely focused on the computer, entering data points, and typing away at a feverish pace.
Patients are not aware that the medicine reconciliation list is a total disaster. Based on my personal experience, I’d estimate it is inaccurate greater than 80 percent of the time. When multiple physicians have access to a patient’s chart, no one actually takes the time to authenticate and confirm changes with the actual current medications. The EMR makes entering changes both time-consuming, cumbersome, and quite challenging.
Utilizing the patient portal as a communication tool is OK if people have computers and internet access. Yet, there are too many elderly patients that simply don’t have the skills to navigate these difficult portals. These sites are simply not intuitive or user-friendly.
To understand the billing summary, you truly need an advanced degree in higher-level mathematics. It is both terribly overwhelming and confusing. The disconnect from what you’re charged to what insurance allows to what you end up paying is dramatically different. I have never understood the term “usual and customary.” At some point, you simply give up trying to understand, pay the bill for fear of being sent to collections, and drop your valid inquiries and concerns, out of sheer frustration.
You’ve probably noticed that physicians don’t communicate directly anymore. When was the last time your personal physician picked up a phone and called a colleague (referring physician or specialist, it doesn’t matter) and spoke openly and honestly about a situation—your situation? It has become simpler just to leave a note in the chart (which may or may not be found) and remain in one’s own silo. This lack of direct communication is hurting patient outcomes.
These observations should not be a surprise and are confirmed by a very recent landmark (Commonwealth) study indicating that indeed the U.S. is ranked last in multiple health care metrics compared to other high-income developed countries, despite spending more. What a shame and how very sad.
I don’t profess to have any of the solutions, but I do fear health care delivery is going in the wrong direction. A major part of the problem has been generated by the digital revolution. The EMR is truly a system aimed at documentation for billing purposes, not for enhancing the health care of our patients.
No one likes to talk about these issues. Everyone seems too busy. The current goal seems to be seeing more patients, doing more tests, and increasing revenue.
Hopefully, we can engage in open and honest dialogue and improve the delivery of health care. Until then, we remain in a tenuous situation where outcomes will be severely compromised. No one deserves less than the best.
Mark Goldfarb is a cardiologist.
