New office “efficiency” procedures set up barriers to direct doctor-patient communication, and this creates potential for malpractice.
Increased risks as doctors lose control of practice management.
By Paul Goldfinger, MD, FACC, double board certified physician.
I wanted to discuss an important medical issue with my gastroenterologist, but my next scheduled appointment is in April, and there are no openings for about a month. What to do? I could try going on line to the “portal,” but I don’t trust that my message would be seen by my doc.
So I placed a call to the office. First I considered the pre-recorded triage message which did not offer me the opportunity to leave a message. I chose the option to “speak to a person at the front desk,” but the prospect of that leaves me trembling with fear.
Ofc: Hello. Dr. H’s office. How can I help you?
Me: This is Doctor Paul Goldfinger and I would like to speak to Dr. H.
Ofc: He’s not here today.
Me: Can I leave him a message?
Ofc: When is your birthday?—I tell her
Ofc: What is this about?
Me: I want to ask him about my treatment.
Ofc.: What about your treatment ?
Me: Who are you? Are you a nurse? (fat chance!)
Ofc: I am a receptionist.
Me: I don’t want to discuss my medical situation with you. Can I leave him a message?
Ofc. Yes, but he won’t be back for 3 days. What exactly is this about?
Me: I will discuss that with him
Ofc. I am required to get more information from you.
Me: It’s about my medication.
Ofc: What about your medication? Tell me the name. —I tell her the name, but it’s like (as my mother would say) talking to the wall.
Me: Just leave him a message to call me about my medication.
She (getting irritated): What is your phone number (I tell her). She says he will call me back when he returns in 3 days. She does not offer me a call from a “covering doctor”who is a species that seems to have become extinct.
END CALL. I have little confidence that this message will reach him and then even less confidence that he will call me back. I am prepared to be my own doctor, but I don’t like the idea. And what if you are a patient who isn’t sleeping with a doctor?
The last time I had a similar situation was with a different specialist who never called me back for 2 weeks even though I called the office 4 times to resend the message. I finally switched doctors but I will probably only get someone else who won’t call me back.
This episode is about a non-medical person who processes my call, but somehow she is given the authority to question me about my medical issues.
All I can say is “disgraceful and dangerous.” All sorts of middle level or lower level personnel have been allowed to muck around with my medical situation.
Office nurses are gone, and sometimes you can get a physician assistant, but now they are hard to find, so you get Madam Butterfly at the front desk instead.
And if you get the PA, they often are clueless as well. As a board certified internist/cardiologist, I will be calling about my complicated dives into the latest studies, so I know that she will probably be useless and hostile.
My experiences with mid level PA’s is that they think they know more than they do, but they don’t know how to take a complex history and they do not know how to do a proper physical exam, and they often will not discuss their assessment with the doctor. So you may be stuck with a pretend-physician. This represents a decline in quality care.
What to do? Who knows?…You have to pray that the new practice systems will somehow prevent you from dying. Next robots with artificial intelligence will be in charge, and medical schools will close
However, surprise! On day 3 Dr H. did call back as promised, but why should we be surprised by the call—-3 days late? But at least there may be hope.
I believe that this and other similar concerns are all based in new cost-effective computerized management in a medical world where doctors no longer run their practices, and Hippocrates gets thrown under the bus. And don’t get me started on hospital practices. We’ll get into that another time.
However, regarding office ding-bats who want to question you about your medical problem: this is from one of America’s most famous doctors Sir William Osler, a founder of Johns Hopkins Hospital” WIKI.
There are solutions to such management issues, but that could be a long time away with doctors and nurses no longer in charge . Patients: pay attention to problems and have a medical advocate to help you, if possible.
THE PLATTERS FROM THE SOUNDTRACK OF AMERICAN GRAFFITI
All too often, receptionists are empowered to take a medical history and then relate the information to the doctor or PA who do not get on the phone. The worst outcome is when the receptionist says that they have no openings, so go to the ER!
Sometimes the PA, not the doctor, may call you later. But delays may be dangerous.
Your event illustrates the breakdown of the all-important “doctor-patient relationship.”
Eliminating a history taken directly by a doctor or a nurse or a PA increases the chance that a life-threatening issue might be missed.
Traditionally if a patient calls with significant symptoms, a nurse would screen the call, and if appropriate, invite the patient to come to the office that very day. ER visits can be awful and may turn out to be unnecessary, and a doctor can provide a wonderful service by seeing the patient in the office or at least speaking on the phone.
If the doctor isn’t involved in such a call, it is essential to keep the doctor “in the loop”.
These days, you may be told that there is no opening in the office and no effort is made to make room for an unscheduled patient–running a bit behind is now forbidden as everyone in the office is under strict pressure to stay on time.
Hippocrates practiced medicine about 2,500 years ago. You should read his oath. Here is a segment:
“ἡγήσεσθαι μὲν τὸν διδάξαντά με τὴν τέχνην ταύτην ἴσα γενέτῃσιν ἐμοῖς, καὶ βίου κοινώσεσθαι, καὶ χρεῶν χρηΐζοντι μετάδοσιν ποιήσεσθαι, καὶ γένος τὸ ἐξ αὐτοῦ ἀδελφοῖς ἴσον ἐπικρινεῖν ἄρρεσι, καὶ διδάξειν τὴν τέχνην ταύτην, ἢν χρηΐζωσι μανθάνειν, ἄνευ μισθοῦ καὶ συγγραφῆς, παραγγελίης τε καὶ ἀκροήσιος καὶ τῆς λοίπης ἁπάσης μαθήσιος μετάδοσιν ποιήσεσθαι υἱοῖς τε ἐμοῖς καὶ τοῖς τοῦ ἐμὲ διδάξαντος, καὶ μαθητῇσι συγγεγραμμένοις τε καὶ ὡρκισμένοις νόμῳ ἰητρικῷ, ἄλλῳ δὲ οὐδενί.”
But, seriously,for thousands of years, the taking of a history by a physician was valued highly as part of the way to make an accurate diagnosis. No matter who obtains the initial history, the doctor or his nurse would get involved and let the patient come to the office that day, no matter how busy they are. Avoiding the ER is a mitzvah and can be effective in many cases.
In my medical school, second year, we took a course called “History and Physical” How to obtain a quality medical history requires being taught proper history taking technique. It should not be left in the hands of a receptionist.
Students are also taught how to conduct a fine physical examination. That was also passed by in your case, and I notice that the physical exam is often given a cursory backseat when today’s doctors see a patient.
Another option that can avoid the ER is going to an Urgicenter, but choose one that is staffed by physicians.
Modern medicine is wonderful in many ways, but without the doctor-patient relationship, whether as an outpatient or in the hospital, the best interests of the patient are not being served.
I remember when growing up and I had repeated tonsillitis my mother would call the handsome doctor’s office (of course his wife was the receptionist) and leave a message. That same day no matter how late the handsome doctor would make a house call.
He was revered in town. He cared. The handsome doctor’s house calls are long gone and it’s a shame. (BTW I refer to him as “the handsome doctor” because my mother had a crush on him and I knew it.)
Everyone in the medical field is totally impersonal now. I can relate to PG’s. recent experience 100%.
I recently called my gastro doctor with whom I had recently completed a battery of tests— some invasive and some painful. I called a week or two later experiencing severe ER-worthy pain, and the receptionist said she would contact the doctor. I got a call back the end of the next DAY, not hour or hours, and the receptionist said the doctor said to take some Mylanta.
I said “Are you kidding?” and hung up. Obviously the doctor had no connection to my name or case even though she had been through the diagnostic journey with me for a couple months. I must be one of a thousand patients of hers.
The system has changed drastically and not for the better.