The Stage 3 proposals for meaningful use came out recently and I cringed at the next level of bureaucracy masked as quality patient care. Mounds of structured data must be collected and reported upon. Patient portals must be utilized by a specified percentage of patients. The government apparently doesn't realize that my impoverished patients, particularly my elderly patients, barely have access to the Internet, even when they know how to use it. My office, a safety-net clinic, barely manages to collect enough money to stay afloat and now I need to jump through even more hoops.
The demands of unproven quality measures, so called "meaningful use" of the EHR, and a constant stream of paperwork have eroded the essential foundation of the doctor-patient relationship. Physicians, in turn, are churning through patients as if going through an assembly line. The quantity overtakes the quality of patient care and this is where we are hurting our next generation of physicians, as well as the patients they take care of. Good patient care, where we are able to converse with our patients, do a proper exam, review relevant results, and completely answer questions, takes time — and time is a luxury physicians no longer have.
Instead of writing meaningful histories we are checking the boxes of a template created by a well-meaning IT developer who has never taken a patient history. It becomes so robotic to check the review of system boxes that we almost forget to listen to the answers from the patient. We are often discouraged from using the free text option because it does not permit the all important data dredging we need from our EHR to prove we are providing quality care. Yet so much precious information is lost in those check boxes, because as many can attest, patients and their conditions rarely fit in little boxes. Sitting behind computer screens that have invaded our exam rooms, we have created a barrier between our patients and ourselves and permitted outsiders to dictate how much time is appropriate for diagnosis and treatment of a patient.
When did doctors stop being in charge of healthcare? When did lawmakers trying to save the bottom line trump our hard-earned knowledge about patient care, pathophysiology, and treatment options? I struggle to explain to my patients that despite what I know they need, they cannot get the care that could prevent another admission to the hospital. First-line treatments require prior authorizations, paperwork to be signed, and decisions to be appealed. No wonder my patients have trouble adhering to medication regimens that are constantly changing. Why can't the regulations pressuring me include regulations for insurance companies to cover basic medications and keep pharmaceutical companies from charging absurd prices that benefit their shareholders, but never my patients?
Under the guise of helping, really all these regulations are doing is hurting. They discourage physicians from wanting to care for Medicaid and Medicare patients, patients that need us so badly. Fewer medical students want the hassle of primary care, even when that specialty interests them. I love that I can care for the patients I do, but I find the struggle exhausting at times. Unfunded mandates for EHRs and third-party certified tokens to e-prescribe controlled substances are supposed to improve healthcare, yet my patients are still left wondering if their prescriptions will be covered or if the copay for the office visit is going to go up again. Patient access does not improve just because I have "open scheduling," especially if more physicians choose to leave clinical medicine because their ability to practice medicine becomes more and more hindered.
I see the cash-only, concierge practices that have been popping up around me and wonder if that is where I will go next. Right now I enjoy teaching residents and medical students, but I wonder too. I wonder if I could actually provide the type of patient care that I try to teach my residents about in that model. If I could create a practice where my patients worry less about their copays and I worry less about meaningful use requirements, ticking boxes, and prior authorizations, I could just be a doctor. That's what I want: just to be my patient's doctor.