Mary Christ, MD, MBA

When it comes to patients and doctors, how close of a relationship is too close?

One of the basic tenets of the doctor-patient relationship that every first-year medical student begins to learn is that physicians must - as a matter of professional decorum -learn to maintain a degree of emotional distance with their patients.  We are told from our very first patient encounters that we must individually discover the formula that allows us to empathetically relate to our patients, while simultaneously remaining objective enough to effectively provide the best possible healthcare.  It seems that this equation is sorted out more readily in some specialties, such as surgery where a certain aloofness has become expected, while in specialties such as mine - pediatrics - it often proves to be a much more dicey undertaking.  After all, pediatricians are generally viewed as the "soft and fuzzy" caregivers who typically go into this field specifically because they want to form close, long-term bonds with their patients and their parents.  So, the dilemma of how close is too close in the physician-patient relationship can be an ongoing struggle for some caregivers, many of whom confide that their opinions on the topic tend to vacillate throughout their careers.

I must admit that I was relieved to learn that I wasn't alone in my quest for the "perfect" balance between nurturing and maintaining enough emotional distance as I grew to know my patients.   Early on in my career, I erred on the side of being overly invested with certain families with whom I had developed a rapport because, quite frankly, I am human and this is what naturally occurs in human bonding.  Over time, though, I began to experience the dreaded realization that I could not possibly continue in this vain as I took on a larger pool of patients.   Eventually, I forced myself to step back and reassess my approach to ALL my families.  Although I didn't want to admit it, I had to face the fact that I was showing a partiality to certain patients and that just wasn't how I wanted to practice.  

During this self-assessment, it occurred to me that if my "neglected" patients ever compared notes with my "favored" patients while seated in the waiting room, a riot of biblical proportions might ensue!  I imagined one of my close-relationship parents unwittingly mentioning to other parents that no matter what time of day or night they call, I am always available and even willing to come into the office late at night to see their child.  Or, perhaps even more egregious, regaling less-favored patients with tales about summer internships I'd facilitated for their child.   I mean, can't you just envision the other parents getting "hot under the collar" listening to these accounts and thinking: "Hey, how come my child doesn't warrant such special attention?"  

After all, who could blame a parent for thinking their child is somehow being cheated out of optimal care when faced with such anecdotal evidence of favoritism.  As a parent, I know I'd be the first in line at the complaint counter if my child was being slighted!  And that's when it hit me:  The litmus test for determining the ideal balance in the physician-patient relationship is what I term the "Waiting Room Rule."  Simply put: Don't do anything in your relationships with your patients that you wouldn't want gossiped about in your waiting room; or publicized on the 6 o'clock news for that matter; or heaven forbid, plastered across social media. 

Once instituted, my "Waiting Room Rule" readily allowed me to provide more equitable attention to all my patients, while eliminating the nagging sense that I was practicing in a partisan manner. It will always be a challenge for me to moderate my tendency toward building friendships with my patients.  But, all I have to do is visualize Facebook or Twitter attacks labeling me "Doctor Favoritism" from disgruntled parents who believe their child was slighted in any way, and it snaps me back to reality.   

Articles

"The Waiting Room Rule" is one way to determine whether or not you are getting too close with a patient and showing favoritism. 

How Close is Too Close with Patients?

Like many of my physician colleagues I have always been a type-A perfectionist who has a propensity to overcommit, as well as a seemingly morbid fear of saying "no" to requests for my time.  All of this changed, however, when I became a mother whose ability to be "all things to all people" was seriously challenged and my son became my top priority.  

As a pediatrician, I found myself in a nearly constant state of maternal guilt as I devoted most of my waking hours to other people's children rather than my little cherub.  My wakeup call finally came after a particularly grueling 24-hour on-call stint when I arrived home to discover that my 18-month old had been up all night screaming for "Mama" as he suffered with severe ear pain.  After checking his ears with my otoscope, I confirmed two things: 1) he had a rip-roaring otitis media and, 2) I had to reassess my priorities.

After some serious soul searching, I determined that I simply had to set clear boundaries around my time commitments.  I approached my time budget as I would my financial budget: There are only 24 hours in a day and those hours had to be prioritized.  By proactively creating my time commitment budget, it allowed me to recognize my limits and be better prepared to say "no" to demands for my time.

Over the years, my time commitment budget has served as an integral part of my personal preventive health plan since it allows me to maintain my physical and emotional health, while preventing burn-out.  I've encouraged my colleagues to view their time as another facet of their health -much as they would their diet or sleep- and proactively adopt a budget they periodically reassess.  

As with any other area of health maintenance, the first step toward improved "time health" is being cognizant of detrimental lifestyle factors such as over-commitment and the inability to say "no."  Once these factors are recognized, a preventive plan can be implemented to eliminate burn-out and improve overall well-being.  

Burnout is akin to a diet consisting of Big Macs and gallons of ice cream: both are detrimental to overall health, but can be readily avoided if you are aware of their harm and have a pre-determined plan to ensure you don't succumb to the temptation. 

Burnout and McDonald's popular burger are a lot like - in that both can be avoided if you don't succumb to the temptation. Here's how. 

Why Doctor Burnout is Like a Big Mac

, Mary Christ, a physician, member of the 

editorial advisory board, and healthcare IT physician executive consultant, spoke with us about a challenging experience she encountered in obtaining optimal care from a nurse practitioner (NP) who was added to her sister’s long-term sub-specialist’s staff.  She reported that it became nearly impossible for her sister to interact directly with her doctor, and she often felt as if she had to become her sister’s personal physician when the NP consistently proved to be incapable of handling her care.  Below are her thoughts on the experience, where NPs fit into today's medical practice, and more:  

My sister’s suboptimal care by an NP did not "cloud" my judgment about the entire NP profession, but it was the instigating event that made me start to think about the entire NP/physician equation.  It actually gave me the impetus to do some research to understand how NPs are trained and then used as adjuvant practitioners.   

I try very hard in my life not to stereotype a group by the actions of a few, so it never occurred to me [after my sister's visit] that all NPs were incompetent or undertrained.  Interestingly, right after my sister’s poor experience with an NP, my initial thought was that her doctor was the flawed piece of the entire puzzle.

I felt as if her physician was pushing off her ‘difficult’ patients, or her patients possibly requiring extra time and/or effort, onto the NP.  Ultimately, this resulted in the NP appearing ill-equipped to properly care for this doctor's particular set of patients.  Like I said, I didn't blame the NP, but I felt as if the physician sorely misjudged the areas where an NP can be tremendously useful.  

This particular physician's patient population includes people with long-term, chronic, rare diseases requiring an exceptionally high degree of medical knowledge, research, etc. This turned out to be a completely wrong place to inject an NP.  And, it's not that there's anything wrong with NPs, it's just that they are not educated or equipped for every role in clinical practice.  After all, my sister’s doctor is a sub-sub-specialist, so how on earth would an NP have much value-add?

Overall, my sister’s relationship with her long-term physician ended because she persisted in trying to offload her work on NPs who merely wasted patients' time and added another level of distance from the doctor.  I discovered a couple of years later that many patients left her practice when they were forced to first make an appointment with the NP, and then could only actually see the physician if the NP deemed it necessary.  This might work with the common cold, but definitely not in an area dealing with rare, wholly-debilitating diseases.

From my perspective, this particular experience allowed me to examine a situation that I may never have given a second thought.  For instance, I've worked with NPs in the ED for years and they are terrific in their roles doing specific, common, repetitive tasks.  A prime example in my ED was a tremendously professional NP who specialized in performing "rape kits" on unfortunate victims; she was wonderful with the patients, and became an expert in performing the tedium inherent to the rape kit procedures.  Similarly, we had NPs who would counsel teens on birth control and administer contraceptives.  

I think the bottom line is we must use NPs appropriately in areas commensurate with their actual training and abilities.  And, even more importantly, there should be close monitoring with specific guidelines as to which procedures, dispensing of advice and medications, and so on they are allowed to do.  One would think this would be an obvious approach to bringing adjuvant providers into the mix, but I fear those steps have been completely overlooked.

One physician shares her sister's experiences in getting care from a nurse practitioner and how it shaped the way she thought about their profession.

An Experience in Sub-Optimal Care from an NP

Healthcare information technology has ushered in a new era in medicine in which the doctor-patient relationship is taking a backseat to the doctor-technology relationship, as many physicians find themselves diverting time away from the patient to deal with poorly designed EHR systems. Of course, the ultimate goal of healthcare technology is to improve patient care delivery, but EHR usability factors are impeding progress and threatening widespread acceptance of new technology.

As I watch my cat entertain himself playing with an app on the iPad, while I, too, jump from app to app on my iPhone, I wonder why EHR systems weren't designed to be as easy to use as many of the applications we encounter on a daily basis. I've even asked myself: WWJD (What would Jobs do)? Imagine if EHR systems were designed using the same standards as Steve Jobs - the usability guru - applied to all of his phenomenally successful products. Typically, end user ease-of-use and productivity are the primary goals of software designers, so why are EHR systems so onerous? Although the answer is complex, it may surprise everyone (and no one) that end-user usability was not a top design requirement as EHR software developers rushed to deliver systems to meet Affordable Care Act requirements.

To rectify the usability problem, the AMA recently announced a framework of eight usability priorities. One priority calls for expediting user input into product design and post-implementation feedback. As physicians whose livelihoods now depend on a healthy doctor-technology relationship, now is the time to influence EHR usability. As a healthcare IT consultant, I am often asked how providers can influence product development. One method I advise my clients to implement is a simple online "help desk" communication system between healthcare providers and their IT group, which allows providers to report problems, ask questions, or recommend improvements. In addition, the system can be a communication vehicle to dispense information about meaningful use requirements, system updates, etc. Information gathered by the system can also be used as input to EHR product developers.

Besides the cumbersome data entry/usability issues, information retrieval is proving to be a roadblock for many physicians as they attempt to utilize the data they have collected. A recent analysis from Frost & Sullivan, "EHR Usability - CIOs Weigh In on What's Needed to Improve Information Retrieval," indicates that the problem is expected to get worse. The report suggests a lack of technology - not end-user ability -is preventing adequate data retrieval. It is believed, however, that as U.S. regulatory authorities focus on the vast complaints about EHR usability, there will be a surge in functionality development by current and new vendors. This renewed focus is a prime opportunity for healthcare providers to inject much needed end-user experience into the development process.

As new, user-friendly systems are introduced into the healthcare IT marketplace, perhaps the usability and end user experiential data could be published in a forum to allow healthcare providers a means to compare systems. I have long envisioned an independent mechanism akin to "UL Approved" or 

 to provide critical comparative data on healthcare IT software applications. Ultimately, physicians and technology must form a symbiotic relationship that returns our focus to the patient.

 a former technology executive, is a freelance healthcare IT consultant and member of the 

 Do you have the opportunity to contribute input on your practice EHR? 

Unless you say otherwise, we'll assume that we're free to publish your comments in upcoming issues of Physicians Practice, in print and online.

This article originally appeared in the January 2015 issue of 

Healthcare information technology has ushered in a new era in medicine in which the doctor-patient relationship is taking a backseat to the doctor-technology relationship. 

The Doctor-Technology Relationship

When CVS recently announced its intention to cease selling tobacco products, little attention was paid to the company's strategic plan to expand urgent care centers in its stores. At a time when Obamacare is predicted to create an onslaught of urgent-care patients, CVS's maneuver could prove to be a brilliant solution to the dearth of physicians by filling the gap with nurse practitioners (NPs). Or, maybe not.

As NPs continue to expand their numbers and scope of practice, physicians have expressed concern about having to compete for patients. Although competition and loss of income are troubling to some physicians, perhaps the focus should be on quality of care and patient outcomes as NPs continue to usurp traditional physician roles.

Consider the fact that a NP can earn a license with less than four years of college via accelerated programs; allowing persons with associate degrees to obtain master's degrees in as few as 18 months. Alarmingly, NP programs require at most 650 hours of clinical work, with NP students often left to their own devices to arrange their clinical rotations in a "catch-as-catch-can" fashion. Moreover, NPs are not required to take cadaver gross anatomy, and have only cursory training in organ system diseases and processes.

In contrast, a physician must have at least a bachelor's degree prior to attending four years of medical school, followed by at least three years of residency and often several years of fellowship. In terms of hands-on clinical hours, the average physician undertakes an estimated staggering 25,000 hours of training.

With physicians having more than 40 times the clinical preparation than a NP, as well as in-depth knowledge of the pathophysiology and disease processes of every organ system, it is mind boggling how NPs have been allowed to rapidly and insidiously assume the role of primary-care physician (PCP).

Given the seemingly desperate call for PCPs, have standards been sacrificed to meet demand? And, what are the effects of allowing NPs to act as surrogate PCPs - especially when NPs are allowed to function autonomously in many states? Certainly, there is a role for NPs as complementary - not replacement physician - caregivers, and the proper oversight and regulation must be instituted to oversee these roles.

As an analogy, would you fly on a plane piloted by flight attendants who, due to cost-cutting measures, were replacing pilots? They do, after all, know "something" about the plane and have finely-honed interpersonal skills.

Time will tell if CVS's "Diagnoses While You Shop" centers ultimately improve or harm the health of our patients. But, given the lack of regulation and outcomes assessments, this patient will stick with her physician and only fly in planes with pilots at the helms.

is former technology executive who attended medical school to merge her passions of computer engineering and medical science. She is a freelance healthcare IT physician executive consultant. Do you feel that nurse practitioners should only complement, not replace, physicians? 

Unless you say otherwise, we'll assume that we're free to publish your comments in print and online.

This article originally appeared in the April 2014 issue of 

Physician Mary Christ expresses skepticism about the expanding roles for nurse practitioners. 