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Undermining the Doctor-Patient Relationship

To provide the best level of care, physicians need to spend as much time as they can with their patients. So why are we asking them to put so much effort into keeping electronic records?
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(Photo: upixa/Shutterstock)

(Photo: upixa/Shutterstock)

With all of the buzz surrounding meaningful use in health care these days, you’d be forgiven for thinking that something truly revolutionary—and meaningful—is transforming the quality of care that patients receive.

Meaningful use refers to a set of provisions tucked away in the American Recovery and Reinvestment Act, passed into law in 2009. Distinct from Obamacare, it mandates that physicians use electronic health records in specific ways to benefit patients, and provides financial incentives to physicians who document their adherence; over time, these incentives will transform into financial penalties for those who do not comply. Although the meaningful-use requirements are sensible and appropriate for many physician-patient encounters, this is certainly not always true, in which case the time spent on them is essentially wasted.

Other documentation requirements mandated by third-party payors pertaining to the content of the physician-patient encounter—and without which doctors are not paid appropriately—consume valuable time that would otherwise be spent in conversation with patients about what ails them and how best to remedy it. And all of this occurs as falling reimbursements result in growing pressure on doctors to see more patients in less time.

With work-duty hours capped at 80 hours a week, that comes out to fewer than 10 hours a week, or fewer than two hours per weekday spent with patients.

This is a big problem. We know that better communication between physicians and patients leads to higher rates of medical adherence, fewer resources wasted on unnecessary testing and procedures, increased use of preventive medicine, reduced bounce-back admissions to the hospital after discharge, and increased patient and physician satisfaction.

A number of recent studies illustrate the scope of this problem. One published half a year ago in Graduate Medical Education surveyed 1,515 trainees in 24 different specialties and found that 90 percent felt that their documentation requirements reduced the time they spent with patients, and that 73 percent believed that this had a negative effect on patient care.

Time-wise, what does this mean? A study published last year in The Journal of General Internal Medicine examining time distribution of interns in two different internal medicine programs found that just 12 percent of their time was spent in direct patient care, versus 40 percent in front of their computers.

With work-duty hours capped at 80 hours a week, that comes out to fewer than 10 hours a week, or fewer than two hours per weekday spent with patients. And in case it’s not clear how this directly compromises patient care, consider the findings of a 2011 study published in The Permanente Journal, in which first- and second-year internal medicine residents were observed in their encounters with patients newly admitted to the hospital. In almost two-thirds of these encounters, the residents spent fewer than seven minutes taking a medical history; almost three-quarters of the patients were not asked about diseases in their families.

What can be done to change the course of a health-care system so focused on process measures and “efficiency” that often seem to come at the expense of the quality of care patients receive? For one, physicians and patients need to speak up and point out the fallacy of pursuing the short-term financial goals that are obtained by pressuring doctors to see more patients in less time and which come at the expense of better medium- and long-term health outcomes. Both groups need to make the case that enabling good physician-patient relationships to flourish is no different than how investing in infrastructure such as transportation and communication is vital to other sectors of the economy.

Second, there needs to be pushback against the external meddling in how physicians manage their encounters with their patients. Face time with patients is what enables physicians to draw upon and dispense their most valuable resource, one which only they possess: the knowledge and experience based upon years of study and work. Having doctors squander their time completing multiple checklists that someone else has determined are necessary and which could well be done by others is a huge waste, and leads directly to worse outcomes.

In their recent book The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care, Charles Kenney and Jack Cochran make the case for physicians to assume a more active role in leading the medical system. However, this is not enough. Patients, advocacy groups, and others who interface frequently with the health-care system need to make their voices heard as well. Until this occurs, physician dissatisfaction and burnout will continue to grow; so too will the waste and unnecessary spending within our health-care system. And health outcomes in the United States will continue to be substandard relative to that of other developed countries.