Saturday, August 07, 2010

When The Doctor's Always In

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 is not a new trend. We saw a similar situation years ago with the advent of the digital beeper. Even the most basic of private bodily functions in the bathroom could be interrupted at a moment's notice. The expectation that phone calls should be returned instantly grew from this - personal context be damned. Doctors were accepting of these intrusions, however; the feeling of being omni-present, omni-available, and omni-beneficent fit nicely with the Marcus Welby, MD psyche of the time. After all, there were financial advantages to being available and the most responsive gained a competitive edge.

But medical care based on electronic communications is commandeering doctors' personal lives. Our instantaneous availability is breathlessly touted by health care systems eager to serve their patient customers. Batches of test results are reported electronically but still require human review - one at a time. With hundreds of thousands of patients registering online for their new level of doctor-patient communication, the requirement to respond quickly to patient requests taxes even the most diligent physician providers. To preserve their personal life and get home at a reasonable hour each day, test reviews and patient communications are increasingly performed from home - all for free. Worse, our similarly web-enabled patient population has learned that many of their health care issues can now be addressed online free of charge - just send a two-page e-mail - who needs an office visit?

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? For the doctors who accept this choice, what are the risks to patients when they interact with doctors who are "crackberry" addicts without personal or family boundaries? Should our medical students expect that their lives will be surrendered to their patients, free of charge, as they answer the never-ending bounty of health care questions online?

Electronic medicine is here with all its bells and whistles - I get that. But it does not come for free nor without consequences to doctors' time and personal lives. Establishing appropriate boundaries for electronic physician access will be our next great challenge, otherwise the last drop of the milk of human kindness might just be wrung from us.



DrV said...

Wes. This is a critical issue that's never never really seen the light of day. SoMe has brought this to light with the belief that "now we'll be talking with our doctors all the time." And when questions are raised, the medical community is indicted for greed.

I'm going to chew on this some more since I have alot of thoughts. I'll make a formal post and send everyone this way....

padschicago said...

Very good post, as always. And well understood! I wish there were more patients sympathetic to doctor's lives. I admit that I can be an obnoxious one to my doctor at times, and I feel very bad when I do. I can be very apologetic. I wish there would be more I could do to help my doctor with his work! I would gratefully take any task to make his job easier. I haven't worked in healthcare for a few years but I can never forget the hard labor involved physically, mentally. I chose the field because I CARE and I love to live and learn and to see the positive changes in people's lives! I credit technology--Twitter and social media especially--with helping me to change. The advances I have made since joining the social media revolution have been truly amazing! I have been described as going from "mousey" to outgoing. My mental health is improving. I am so much happier! Hopefully someday soon I may no longer be known by my doctor's office as the crazy patient who emails them all the time with questions or requests, and will deal with things on my own or at office visits. :)

Medical Quack said...

Dr. West as always some very good and real points, things that others don't always think about. Being on call today with technology has taken on a new look for sure.

For one, there's a lot more to be on call about too as we have more knowledge, diagnoses processes, treatments an so on, not to mention so many more ways to get in touch.

As the part time half of a hospitalist, primary MD and a doc that assists orthopedic in surgeries, you can figure out how much personal time is available there, but gives me a lot of time to blog:)

If it's not the hospital calling, there's patients leaving messages and this individual is known for getting back right away too as it is how he works, and then there's the calls that come in when the other guys don't answer:)

So getting to go out for a nice dinner on a Saturday night can be a real treat and then the pager goes off and there are times when dinner is cut short of course.

In addition there are times too when a patient is having an anxiety attack over a yeast infection she thinks she has, but the phone message didn't say that so 20 minutes on a phone call returned to the patient, dinner gets cold after referring her to the drug store for an OTC and relaying all kinds of other helpful information. Of course he reminds her to dial 911 if this an emergency too:)

It all goes with the territory of course but patient has their level of importance and in this instance a text message on what to do about her question would have been very welcome or even the patient thinking about looking it up on the internet:)

Dinner got cold but still was good and luckily the pager was quiet for the rest of the dinner:) You are right on the boundaries and just some common sense at times is really helpful too:)

Becca said...

While this is a critical issue, I think it's one that might (hopefully!) become dated.

Exhibit A: My buddy John gets to play all day with other doctors, developers, academics, engineers etc. creating the technology that will, as they say, catalyze a revolution in human health. Implicit there is the revolution that will happen in care delivery--a major vision in this lab is that doctors become copilots to their patients' health. Check out the demos they have of the use of media in treatment of chronic care patients, it's phenomenal! What makes a piece of technology "good" is the ease with which it can be made to disappear. Cue research in decreasing treatment burden on patients (hi!!).

So what's required from future doctors? The ability to collaborate and innovate. Becoming a physician does not (and should not) require the sacrifice of a physician's life--how can you be a practicing humanist if you don't have time to be human?

It will require the recruitment of creatives into medicine and emphasis on innovation in the med school curriculum, if you want a first step. But take heart! The change in the culture of medicine is happening.

Emily Lu said...

Thanks for pointing out what is obviously a very important and critical issue.

I was thinking about this in the context of other professions, and I can think of many instances (i-banking, consulting, running your own business, etc.) where people's businesses dominate time outside regular business hours and are often secondary to clients'/supervisors' demands.

But in all these cases, the inconvenience seems mitigated by a couple things not effective in doctoring, at least for now:
- adequate compensation for their time (either through an initial contract or pay-by-hour)
- a shared cultural understanding of what is an "acceptable" request after-hours and what is something that will be dealt with the following morning (because this will vary by physician to physician and thus patient to patient, with the amount of technological integration only being one piece of that puzzle)

Until we address these two components lacking in the current system of medical care, I think that you're absolutely right - this problem is going to persist, and it's going to get worse.

So, for my part, as someone who is just going to get her white coat this afternoon, I really, really hope that it gets better.

Anonymous said...

Hi Dr. Wes

One of the things that I love about the telepsychiatry job that I started in February 2010 is that when I am "on", I am fully and completely available to anyone in the state in our established network who needs mental health assessment and treatment at ANY time. This usually means during an eight or sixteen hour shift. A positive byproduct of that kind of job for me is that when I sign out of the system at the end of my shift, I am truly "off" as far as that job goes. No phone calls, no beeper, no voice mails, no emails from patients. I may have various practice related emails to read the next time I come in, but I do NOT access these at all from home, ever. During a week like this one, I will only work two days. This means I can focus on my patients while I'm there, but have time to visit with my granddaughter at home the rest of this week. I can be fully engaged in both places. Boundaries are important to the mental and physical health of the physician and should be fostered, understood and respected.
Thanks for an excellent post.

BobbyG said...

Very nice post. I have to agree. Everyone needs their private space and private life.

clobbered said...

There are two different issues, surely. One of them is whether immediate medical advice via e-mail is a good thing. The other is, whether it should cost money.

My answer is yes and yes. A long time ago I paid a lot of money for a ER visit as a new parent because I had no way to ask a simple question and there was no other out-of-hours assistance available to me. A simple e-mail of "how concerned should I be about this" and a response of "don't worry, it can wait until your paediatrician re-opens on Monday morning as long as X Y Z" would have saved me time, stress, and money - and I would have happily paid $20 for it.

These days my insurer offers exactly such a service direct (though I have not had to use it). It would do in a pinch, but obviously it would be even better if it was done by my doctor or someone with access to my records at least.