By Dr. Chris Magryta

For the Salisbury Post

I have always prided myself for not complaining about the problems of my life whether physical or mental. I am going to break that code now out of necessity to tell a story to my patients and all patients.

 

The Erosion of the Doctor and Patient Visit.

 

When I was at Emory medical school in 1994, we were starting to use computers for our patient charting. As a student dedicated to one patient, it would take me an hour to type in one patient encounter. As a medical student this time was expendable although still unproductive. When I moved to the University of Virginia for pediatric residency training, I was grateful to be back in the paper patient charting world. My early years at Salisbury Pediatric Associates were more of the beautiful paper chart. The patient was the focus of the visit. Life was good.

Years passed and medical computing companies began shopping their electronic medical records (EMR) products to us. They touted cost savings, legible and transferable documents, and improved efficiencies of patient care. We waited because of costs and fear. We wanted to see how other group’s responded to the touted benefits.

During the late 2000’s great pressures were brought upon the medical community to make medicine all electronic.  The Federal government and hospital systems were pushing this agenda despite physician fear and resistance. Unfortunately, this has turned into a first class debacle. The fear of not being paid appropriately if groups did not switch to EMR and the offer of time limited government funding to help defray the expensive startup cost started the dominos falling toward EMR. What happened?

What we got for our money was hundreds of different systems in the country that do not talk to each other, make the practice of medicine less efficient, (My partners and I are currently 20-30 percent less efficient now than during the paper chart years.) reduce the quality of the note for review and to date generally add little value to the patient or provider.

One of the smartest physicians that I know and my greatest mentor retired early instead of having to deal with the new world of cumbersome medical electronic records. The great University of Virginia would rather let him retire at a young age than find him an aide to manage the medical record. Money. That was tragic for the community where he practiced. My personal loss is great. Brilliance of this sort is rare.

There is no debate that we need an electronic health record that serves the patient and the provider. Unfortunately, we have neither in the current system. We have a system designed to benefit the insurers and the data miners. There it is. I said it.

For point of reference, imagine using a 1990 pc with its programs to do business in today’s market and that is how we physicians feel today. Every other industry in the world benefits from computing for quality and efficiency, we have the opposite effect. The systems are slow, cumbersome and dramatically reduce provider efficiency while dramatically raising stress levels. I once told someone that I wish Steve Jobs were alive to take this mess over and deliver a system that benefit the patient and the provider, the only two people that should matter. He would not have released the system until it was a win for all. This system seems to only benefit the insurers and data miners who care more about the diagnosis than the patient or provider and the interaction.

What we need is one system that traverses the entire medical community and is not used until it has proven to enhance medical care and be efficient.

This does not exist in today’s medical practice.

Patients are now treated to a physician who is busy staring at a screen in order to check all of the required boxes in order to meet the insurance companies and the governments desires for a quality visit, so called bullet points. Let me be very clear. This has in no way improved the quality of care that I deliver. I reiterate that I am on average 20–30 percent less efficient in my daily visits. As a healer I am irritated that this obstacle impedes my ability to see more patients.

I find myself apologizing to my patients for the computer time and my lack of eye contact at times. I find myself constantly trying to catch up and be on time with my visits. Remember that I used to see more people, chart and have more time to teach and educate each patient. That was quality care.

I am less interested in training students now because of the loss of my free time and wasted time.

You may ask what is the point of all of this or that you do not really care.

The point is that for better or for worse the quality of the medical experience is eroding and is likely to do so for the foreseeable future. Doctors are much less happy with their career choice and that is translating into higher stress levels and increased numbers of physicians quitting general practice and going to concierge medicine or places like the VA where working hard is less common as noted in the recent press. (sad but true) It is my belief that patients will start to experience a divide in quality as the bright and frustrated move on to other careers or charge cash for services. It is happening every day.

Now, let me be clear that I am not solely blaming EMR for this problem, however, it is a very large piece of the problem. For me, it is the 800 pound gorilla in the room.

I hope that you will forgive the parts of the system that are taking our eyes away from you. We are still devoted to you and your child. I, personally, promise to try and remain calm if I get behind which is more common place now even with a lighter case load. I will still likely apologize for the computer and ask for your indulgence. Somehow it makes me feel better.

 

Where is the teaching?

How often do you feel like your physician teaches you how to heal yourself? “Rarely” is what I hear from adults. The time constraint is part of the problem, but the bigger issue is the training environment. We have trained Americans over the last few decades that pills will help you. Take the antacid commercials on TV. They espouse eating whatever we want because this magic pill will reduce the acid and your pain is gone. This is true, at least for a while. The pain will go away, but what about the disease? What they don’t tell you is that reducing the acid in your stomach will increase your risk of infections, reduce the digestive process and increase your risk of food allergy and sensitivity.

It takes time and effort to convince a patient that they can reduce their heartburn and fatigue by changing their diet. Prescribing a pill takes a minute. A physician gets paid the same either way. What a mess! Sir William Osler would cry if he saw the quality of our preventative medical care system. We are a poorly functioning disease management system. We plug a hole at a time until it blows open and we suffer. We need to find a way to get back to teaching healthy eating, exercise and spiritual growth in the office. Now that would be a goal worth fighting for.

I often teach my teenage patients that they are in control. Someone once told me that health is the top of a stool. The three legs represent nutrition, spirit and physical activity. If one of the legs breaks then your health will suffer. Take for example an adult that eats well and exercises but is spiritually ungrounded and then goes through a stressful marriage separation. Often that individual will suffer a new disease issue.

Encouraging teens to develop the awareness of issues with a metaphorical leg and to change their behaviors before the inevitable stress arises is a lesson worth giving. I have added a fourth leg to the stool that represents chemicals. This new category is a large part of modern disease development. Avoiding chemicals and toxins in our environment is a major piece of the health prevention paradigm.

Unfortunately, I had to go back to school in Arizona at a pricey expense to find this rhythm in teaching. This really should have been a part of medical school.

Getting there will take an overhaul of the medical training system. All of the hallowed halls of medicine will need to change teaching from disease management to disease prevention. We are starting to see these inroads occurring with experts like Drs. David Katz at Yale, Alessio Fasano at Harvard and Andrew Weil at the University of Arizona pushing this agenda. These champions need more followers to shift the needle. The good news is that they are coming.

In our practice, we have embraced the prevention strategy in full and are actively teaching anyone who will listen to the prevention ethos. We are looking at a model of group visits that involve extended teaching modules on lifestyle medicine. We provide a weekly prevention based newsletter that is geared toward parents and their children. Preventing disease is much easier than treating it and we are committed to this path. We hope that you are as well.