When doctors develop [patient] portal hypertension [PODCAST]

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“Physicians today are confronting yet another epidemic, one that affects doctors directly and is not caused by a virus. It is the result of the ‘patient portal’ through which patients send typed messages directly to their physicians. Though the portal has benefits, anecdotal experience suggests that high message volume is having a deleterious effect on doctors’ blood pressure.”

Paul L. Fine is an internal medicine physician.

He shares his story and discusses his KevinMD article, “What to do when doctors develop ‘portal hypertension.’”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show, we have Paul Fine. He’s an internal medicine physician. He wrote the KevinMD article, satirically slanted, “What to do when doctors develop ‘portal hypertension,'” portal being, of course, the patient portal. Paul, welcome to the show.

Paul L. Fine: Thank you. Glad to be here.

Kevin Pho: So we’ll get into your article in a little bit. First off, briefly share your story and journey to where you are today.

Paul L. Fine: Well, I’m from Ohio originally, and I went to medical school at the University of Michigan and never left. I stayed on as chief medical resident in internal medicine and have been a faculty member ever since.

Kevin Pho: Excellent. So take us through a typical day. You’re an academic internal medicine physician. Walk us through a typical day.

Paul L. Fine: A typical day varies, which is one of the things I like about my job. Most days I have at least half a day in clinic as a primary care doctor, and I do a lot of teaching in various venues here as well. And I even do hospital work, which is getting to be a rather rare combination these days, to do both outpatient and inpatient. I do that about three months per year as well.

Kevin Pho: So tell us about the evolution of the medical students. Have there been any changes over the years in terms of their interest in general internal medicine, something other than primary care?

Paul L. Fine: It’s not a primary care-focused medical school, I guess I would say. The same is true with our residency program. But we do our best to plug it, and we do get a lot of people into internal medicine, at least, but many of them go on to do gastroenterology or cardiology, etc., as you might guess.

Kevin Pho: All right, so tell us why you love primary care. For those medical students who may be listening to the show, and I’m an internal medicine physician myself, I do primary care, and you do primary care as well, why should medical students consider it?

Paul L. Fine: I like primary care, I guess, because of the breadth of the cases and information that you have to be familiar with, ideally, and because of the relationships that you build. One of the things that I’ve come to the conclusion of over the years, and you may have had the same observation, is about the relationships. Honestly, I look at my schedule every day and I think of it as friends coming to visit.

I don’t want to idealize it too much, but I’m an idealistic person. You go through the list and think about all the things you’re going to cover medically, but also the things that you’re going to talk about: recent vacations, what books people are reading, and sports events that are coming up, including interests in college football, and who knows what.

Kevin Pho: How did that make you feel? So give us an example of that. Take us into your exam room. Give us an example of a patient you’ve been seeing for maybe several generations, or for many years now. What kind of patient is that?

Paul L. Fine: I don’t know how to give an example, necessarily. It’s nice that there’s such a wide variety of patients. I have people who come in and we talk about poetry; they bring me a poem, I share a poem with them, and that’s something we look forward to. With others, as I said, we’re talking about what’s going on in college football, and with others we’re talking about grandchildren. I have a lot of patients who won’t tell me how they’re doing until they’ve first heard how I’m doing and how my family is doing. Isn’t that wonderful? That’s the primary care thing.

Kevin Pho: Excellent. So let’s talk about your KevinMD article. It’s a satirical one, “What to do when doctors develop ‘portal hypertension,'” portal, you’re referring to, of course, the patient portal that we all know and love. So tell me about the events that led you to write this article on KevinMD.

Paul L. Fine: Well, no specific event. I’m sure that the portal messages are a mixed blessing. They are a very helpful way to communicate with patients and for patients to communicate with us, but at the same time, the sheer number of them has exploded in recent years, and it burdens us just for that reason. So it’s a big topic in terms of burnout and people having work to do in the evening.

Kevin Pho: Give us an example of that. Under a typical workflow, or on a typical day, tell us about that intersection between those patient messages and what you do during the day.

Paul L. Fine: Well, during the day, of course, you’re seeing patients in clinic, talking with them, examining them, writing the notes, and moving on to the next one, and in my case doing a lot of teaching or hospital work as well. Somewhere in the middle of all that, you have to find the time to look at the sort of electronic walk-in clinic, as it were, that you have, where patients are coming in and electronically asking questions and asking things of you. Sometimes it’s a straightforward thing, and sometimes it isn’t. And again, there can be a lot each day, and of course they come in the evenings, on the weekends, on holidays, etc. So it’s a balancing act, trying to do it well enough but not be overwhelmed by it.

Kevin Pho: On a typical day, give us a ballpark figure. How many of these would you have to address?

Paul L. Fine: On a typical day in my clinic, I would get somewhere between 10 and 15, although I probably have fewer than many of my colleagues, because I’m not a full-time primary care doctor, because of all the teaching that I do and the inpatient work as well.

Kevin Pho: And what are some examples of questions that patients ask you through the portal?

Paul L. Fine: It can be anything from “May I have a renewal of this medication?”, which is probably the most straightforward, to “Here’s a list of eight new symptoms that I have, all of which are quite disturbing to me. Can you help me with them?”

Kevin Pho: All right, so tell us about the satire in this article. Tell us in general how physicians view patient portal messages.

Paul L. Fine: Well, the idea for the article was to address what is a serious topic in a lighthearted way. The idea was, if portal messages can be a significant burden, and I hate to use that term, burden, but a lot of time spent and that kind of thing, then what could we do to make it better in a sort of lighthearted kind of way? What could you see in a patient portal, by way of changes, that might make it a better experience for the doctor? So that was the original idea.

And then, of course, because it’s called a portal, I thought about the fact that so many doctors opening up the inbox and seeing, say, 20 messages would have a spike in blood pressure. So that led to the term “portal hypertension,” obviously a little different in this context than what the hepatologists would use. And I went from there.

Kevin Pho: All right, so give us some ideas. How can this whole experience be better?

Paul L. Fine: Well, as I said, most of this is a little tongue-in-cheek, but one of the things I talk about is having, for example, random joyous surprises. The idea is, where every message tends to be either something that’s troubling somebody or something that you need to help with, it would be nice if every so often you clicked on what you thought was a real message, only to find out that it was a nice cartoon that would make you laugh, or a video of puppies, or a photo of your grandchildren, or a piece of music that you like. So that was one of the ideas, just randomly allocating some of the messages to be that kind of surprise.

Another one that I had was having a certain percentage of the messages just be patients getting back in touch with you to say, “I feel fine, and I think you had some part in that, doctor, and thank you so much.” There’s a bad-news bias, obviously, in portal messages, because people don’t tend to communicate with you as much when they’re feeling fine as they do when there’s a problem. So that was the second one.

Kevin Pho: Absolutely. Wouldn’t it be nice if there were these random joy surprises, or if you just had a random message, maybe thanking you for what you do? That indeed would be a surprise.

Paul L. Fine: Yeah. Another one that I had, which sadly I don’t think we can figure out how to do technically, was getting a message on a given day that tells you that something that you did really made a difference. As a primary care doctor, a lot of what I do is massaging probabilities. So you start a statin, you treat somebody’s hypertension, and all that kind of thing, and the idea is that you’ve made an adverse outcome less likely, but you never get the same kind of surgical satisfaction of knowing that it really made a difference.

So part of what I had hoped for in my little satire here was that you would get a message, say on November the 10th, that says, “Today is the day that this patient would have had an MI had it not been for your fabulous care, and starting the statin, and controlling his diabetes, and convincing him to stop smoking,” and all that stuff. So a little feedback of that kind would be very welcome as well. I just haven’t figured out how to do it yet.

Kevin Pho: Oh, for those electronic medical record companies who may be listening to this, this certainly would be a point of improvement, perhaps encouraging patients to write portal messages that are maybe not so problem-focused, perhaps something more encouraging.

Paul L. Fine: Yep, I’m all for it.

Kevin Pho: Now, on a more serious note, do you have dedicated time to do these messages during your day?

Paul L. Fine: We are getting some more time. In general, the answer has been no. Our particular division has been very supportive of reformations in time to try to make this better. So they have carved out, I think, 20 minutes within every four hours of clinic time to spend working on these messages. That doesn’t seem like a lot of time, but it does help, for sure.

Kevin Pho: And I would say, for a typical message, let’s say something more than a medication refill, if someone asks you a legitimate medical question, how long does it typically take you to respond to something like this? And at what point would you just simply ask the patient, “Hey, this is something that requires an office visit”?

Paul L. Fine: The average message probably takes under five minutes, I would say. I have a few that take longer than that. But sometimes, as you know, it would be impossible to do it entirely through the portal, even with the ability for people to attach photographs, which they do not uncommonly, and we sometimes try to make clinic appointments.

Part of the problem for me is that because of all the other things that I do, and the fact that I’m not a full-time outpatient doctor, even finding the time to see somebody in the clinic can be problematic. So I may be more eager than some of my colleagues to do more of it through the portal, just because access in person can be a little hard to come by.

Kevin Pho: So among your primary care internal medicine colleagues, what are their views in general regarding these asynchronous patient portal messages?

Paul L. Fine: My guess would be that most of my colleagues would agree with the statement that it’s helpful in patient care, but the sheer volume of it can be problematic for the doctor.

Kevin Pho: And what can physicians do to push back against this? Because I happen to agree with you. I do think that with this asynchronous communication, especially for primary care physicians like ourselves, where it may take months to have an office visit with a specific patient, there is certainly a use here, but perhaps with limits, perhaps a word limit. If it requires you to write paragraphs in response, that’s probably not appropriate for a portal message. What are some avenues by which physicians can push back against this? Because I’m sure, from an administrative standpoint, they may not have a lot of sympathy for the time it takes to do this from a physician standpoint. But is there anything that individual physicians can do?

Paul L. Fine: That’s a great question. I think at our place, at least, they’re talking about trying to get more of the messages handled, ideally, before they get to the doctor, if it’s possible, by nurses or advanced practitioners, that kind of thing. I think the word limit can be helpful as well. In fact, one of the earlier versions of my piece included a little paragraph on word limits. It’s tough, because you want people to be able to say what they need to say, and if they need more words to do it, sometimes that’s needed. But overall, as you know, it is a little disheartening if you open up a message and it’s several paragraphs long. So it would be nice if they were a little more succinct.

Kevin Pho: We’re talking to Paul Fine. He’s an internal medicine physician. We’re talking about his satirical article, “What to do when doctors develop ‘portal hypertension,'” and we’re talking about patient portal messages. So Paul, in your ideal world, if you were to completely redesign primary care, how would you design asynchronous digital communication between doctors and patients?

Paul L. Fine: I don’t know that I would redesign it so much as I would make sure that we had adequate time to address it, and that we treated it as an actual visit, in a sense, in that there was credit for it. In a sense, now one can bill for these, if you spend enough time on a given message. I don’t want to focus on the billing, necessarily, but the idea that people recognize that this is truly the delivering of care, and that it therefore deserves to have a place during the average workday that is carved out for it, would be helpful.

I think it’ll be easier to do that if insurance companies come along and allow billing for it, so that it seems to doctors and administrators alike that this is a productive use of doctors’ time, instead of something that they’re doing in the evenings.

Kevin Pho: And what do you see as the path forward in the foreseeable future? What do you see as the future for patient portal messages?

Paul L. Fine: I think it’ll continue to expand. I don’t see any way of pushing back on it, and as I said, I think it’s useful. I just think, as I said, that we need to recognize that it has become what it has become, and try to make allowance for it from a time management standpoint and a credit standpoint, either financially or in terms of time allocation, and the recognition of the amount of time doctors are spending.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Paul L. Fine: I guess the bigger message that I haven’t already touched on is just that in a job that we have, which can be burdensome and stressful and sad at times, it’s nice to have a sense of humor about it.

Kevin Pho: Paul, thank you so much for sharing your time and insight. Thanks again for being on the show.

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