Inbox: Fast Food Medicine

August 26, 2016
Erica Sprey

In our recurring blog "Inbox" we share comments from physicians and practice administrators telling us what keeps them awake at night.

Editor's note: We work hard to write about issues that will help physicians run their practices in a manner that is both prosperous and efficient, while still delivering quality patient care. And we are delighted when our readers let us know what they are thinking. This month we are excerpting a blog by primary-care physician Jennifer Frank on her frustrations with "Dr. Google" and an article by associate editor Erica Sprey on crumbling patient boundaries. The articles has been edited for space and are followed by comments made by readers at PhysiciansPractice.com.

When Dr. Google Trumps the Physician

Warning - I am about to complain. I am about to say some things born of frustration. However, I strongly suspect that this will resonate with other physicians out there. I am used to patients coming in having obtained a pre-visit consultation from Dr. Google. More recently, this seems to have transformed from an in person comment of, "I think my symptoms might be from an ear infection" to a phone call dictation that goes like this, "I have an ear infection. My spouse looked in my ear with our home otoscope and it is red, so I'll need you to call in an antibiotic." In the past few weeks, I've had patients inform me that they need a CT scan ordered or request specific treatment based on a home test of some sort.

I respect my patients. They are experts of their own bodies. I enjoy partnering with patients and shared decision making. What I do not enjoy is having my medical education and clinical judgment bypassed by the patient's own medical summation. Patients are often right about what is going on and I listen carefully to what they think might be causing symptoms. However, even with medical knowledge and clinical experience, I cannot diagnose strep throat over the phone or determine what diagnostic test is the most appropriate for a particular symptom or even if the testing is necessary.

Natasha writes: Exactly, I cannot afford to keep my office running unless the patient turns up in the office to see me.

Rama says: I share the same frustrations! Yes people go to Dr. Google, self-diagnose, and say it is waste of time to come see us to get an antibiotic, as they know what worked for them in the past. Or [they want us to] send a referral to a specialist, as they are convinced only a specialist/procedure/costly diagnostic test will help solve their problem. Reimbursement systems have to change where they compensate for our time and expertise whether the advice, treatment, or recommendation is given over the phone or in-person.

What is your policy when patients ask for over-the-phone consults? Tell us what you think.

Crumbling Boundaries Between Patients and Doctors

Physicians manage multiple conflicting domains: diagnosing and treating disease, complying with payer rules, and using what's been called cumbersome EHR technology, to name a few. While that may not be anything new for agile, multi-tasking physicians, it leaves little time to connect with patients. And connecting with patients has taken on new urgency as physicians are now judged on their ability to make patients happy, via satisfaction surveys like the Consumer Assessment of Healthcare Providers and Systems (CAHPS). But as any experienced physician knows, relaxing the professional boundaries that are so necessary to establishing an effective provider-patient relationship can be problematic.

Barbara Malat, a retired, certified physician assistant (PA), who practiced family medicine for 22 years, most recently in Rochester, Minn., says it is becoming harder to maintain patient boundaries for many reasons. Due to a prevalence of direct-to-consumer pharmaceutical ads on TV and homeopathic cures touted on social media and the web, many patients are becoming anxious, fearful, and demanding. "I actually had one young woman call me and say, 'I'm really anxious when I go to parties and I don't know anyone. I think I have social phobia. I saw that commercial on TV and I'm sure that is the medication that I need,'" says Malat.

If you find yourself experiencing similar pressures and wonder how you should respond to increasing patient demands for specific treatments that they may not need, in order to maintain their good will, here's what other physicians and consultants are saying.

Carol writes: I'm an NP and work in one of those walk-in clinics where we see patients who do not have a primary-care physician (PCP), or couldn't get in to their PCP until next week, or just don't want to wait. I have been cursed at, yelled at, and called dumb for not prescribing antibiotics for viral illnesses. We sometimes can develop a relationship with our patrons but often they think they can tell us what they want and will get it. It's a "have it your way" kind of attitude and it can be quite frustrating. I sometimes feel our clinics are too convenient and if the patient would just wait through the symptoms, such as a URI, they would be better by the time they could get in to see their doctor. I love most of what I do, but the ideal that the patient is always right is a tough thing to manage.

Andrew says: It is crazy they blame the physician for the lack of time [spent] with patients. Maybe the shadow coach can be put to good use and become a scribe to input the information that is discussed with the patient, thus alleviating some of the [doctor's administrative burden and re-establishing [their] human connection with the patient. I find it crazy too that in the article it says, "Many patients nowadays seem to have an expectation of instant access to medical care." What is wrong with this? There is already a model for this and the busy physician should tell the patient who wants this, and/or the physician should join or start such a practice.

Cephus comments: Like most articles of this type a "blame the victim (physician)" attitude is taken. The pressure of MACRA, PCMH, CAHPS, CMS reimbursements will cause physicians to have their Kronstadt moment. With the decreasing number of primary-care physicians available and the increasing number of patients to be served, the answer is obvious. Choose your patients wisely and have the others go to urgent care, the hospital, or the ER. [Is this a] deplorable mind set? No it is a very stark reality thrust upon us - like pancreatic cancer. The solution is [as said in] the article [open] a "micro-practice" or as my personal physician has done, concierge practice. This country's burden of medical care is not an individual physician's personal burden, the Hippocratic Oath is patient centered and this government's edicts/programs/reimbursements and definitions of quality are orthogonal to what is STILL one of the most honorable of professions. Letting legislators define a good physician is akin to letting Stalin define a good worker.

Sarah says: Please don't dump all of your difficult patients at urgent care. Seeing so many difficult cases all day that no one else has time for in an arena where patients expect in and out "fast food medicine" is unsustainable.

Leann writes: Thank you for commenting. I'm curious: Do you work in urgent care? I have met a few physicians, NPs, and PAs who do and who like many aspects of their practice, although they feel mainstream medicine unfairly judges them. I have mixed feelings about urgent care. While I understand the unmet needs that urgent care clinics meet (better than private practices and EDs for sure), I don't believe they are financially sustainable on their own. In other words, I believe pharmacy chains are OK breaking even or even losing money on the urgent care clinics because you, the patient, while you are there buy over-the-counter snake oil and highly marked-up mascara. I'm so curious about the urgent-care business model and want to learn more.

JD says: My perspective comes from my career as a solo private-practice physician for 17 years. While the intentions of these extenders is good, they are not physicians. For a lot of "straight forward" aspects of clinical medicine, these professionals can help to ease the burden of our national physician shortage. For now anyway. Things are pretty bad. They can only get better.

Do you feel patients are becoming more demanding and less respectful of physicians? Tell us what you think.