Periodically we should reflect on what challenges face patients and physicians. Over the past few days, I have worked on a list of the issues that concern me the most. I welcome suggestions for expanding the list.
1. Diagnostic errors. All patient care requires that we make the proper diagnosis. Too often we make errors. A recent paper estimated that 30 percent of cellulitis admissions did not have cellulitis. A similar paper found almost the same estimate for community-acquired pneumonia admissions. The most common reason for successful malpractice claims is diagnostic errors. Have they increased? Members of the Society to Improve Diagnosis in Medicine believe that we have both systemic and cognitive problems that lead to diagnostic errors. Some of the systemic problems are addressed later in this list. One most important problem is the requirement that the patient has a diagnosis prior to admission. As an academic hospitalist, working at a community hospital and VA, I see patients who have a diagnostic label without sufficient information to attach a label. Too often this leads to diagnostic inertia. When we allow that to occur, we have both a system error and our own cognitive error.
2. Documentation requirements and EHRs. CMS, in a classic bureaucratic inane solution to some physicians overcharging, developed an indecipherable, illogical set of expectations in routine notes. Our notes have become unreadable, and the key aspects of a good note – assessment and plans are sometimes found after going through several pages of cut and paste pseudo-documentation. The EHRs are not user-friendly. They require too many clicks and too much time. Documentation and EHRs take physicians away from patients.
3. Burnout. This problem is related to problem #2 and the inane insurance payments. Too many physicians spend insufficient time with their patients because seeing more patients creates more income. The result is dissatisfied physicians and patients. Paradoxically when primary care physicians spend less time per patient, they often order more tests and consults. Thus, we can argue that our payment system leads to increased costs and less satisfaction from patients and physicians.
4. Performance measures. I first wrote about this in 2005 (yes this blog actually started in 2002). Too many bureaucrats believe that we can measure quality through performance measures. Performance measures can help us in very select situations to improve our own practice and systems, but the current use by insurance companies (including CMS) just adds to the cost of providing care: both monetary and time costs. The vast majority of clinicians will tell anyone how stupid many measures are.
5. Heroin. During my training, heroin was rampant. Then cocaine took over as the major drug of abuse. But for several reasons opiates have returned. From a dealer’s viewpoint, opiates are the perfect addiction. Withdrawal is brutal, so addicts will do almost anything to get their fix. We could blame physicians, and certainly, physicians have, in many situations, overprescribed opiates. Since a percentage of opiate users do become addicted, we should restrict starting opioids when at all possible. We could blame the drug companies that have “pushed” opioid use, and that is certainly a likely contribution. We could blame the drug cartels who not only supply heroin but also lace it with other even worse opioids. We want a simple solution. We would like to throw money at the problem to “solve” it. But we really do not know what to do.
6. The relative lack of experienced clinician educators. Our medical schools have systematically undervalued clinician educators for the past quarter-century. Dr. Jack Ende wrote about this in a wonderful article “Bigger Chairs at Smaller Tables.” In this article, he argues that the Chairs of Medicine were once giants and heroes. They held the faculty and learners to a high standard. But in 2017, we have a few star clinician educators at each institution. We see promising young clinician educators stay for 3-5 years, and leave because they do not see the medical school valuing them adequately. We have too many young, inexperienced educators dominating the clinical teaching.
There are certainly many major issues that I have not recalled or forgotten. Please let me know what we should add to this list.
Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.
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