This is the third Labor Day of this blog. I usually take the opportunity to mark the lack of progress in the physician work environment and this year is not much different. All of the usual corporate and government buzzwords being promoted to suggest why physicians need to be managed by somebody who knows nothing about medicine. All of the hype about computerization and how the grossly overpriced electronic health record will save us all, even as the printout from that record looks less and less coherent. I just read a copy of The Institute from the IEEE on Big Data. From that report:
"It's is estimated that the health care industry could save billions by using big-data health analytics to mine the treasure trove of information in electronic health records, insurance claims, prescription orders, clinical studies, government reports, and laboratory results.
Analytics could be used to systematically review clinical data so that treatment decisions could be based on the best available data instead of on physicians' judgment alone...."
The state of current electronic health records as the worst value in the information technology sector is is probably not too surprising given the above observations or the following:
"Instead of seeing only 20 patients a day, doctors are able to see 75 to 100 people and get ahead of the wave..."
I don't know what kind of doctor sees 75-100 patients a day or what the quality of these visits is, but I have never met a physician who wanted to see that many people in a day and wonder if it would not trip a billing fraud flag somewhere in the CMS data base. I have talked with many physicians who were overwhelmed by coming into the office and having 200 tests to review and sign an additional 30-50 orders in addition to seeing 20 patients that day. We are decades away from any machine intelligence being incorporated into the medical record. The current EHR has destroyed the narrative, especially in psychiatry and converted the basis of care to a checklist. Instead of higher order machine assisted decision making the electronic health record has not resulted in the expected savings or utilization of technology. Paying tens of millions of dollars in licensing fees per year and larger IT departments with thousands of PCs running 24/7 to access the sever farm has not produced a nickel of savings and has added large recurring costs.
So I have not noticed any striking improvements in the practice environment. At the same time, it is at such a low level that it is difficult for me to say that it has deteriorated any further. The American Psychiatric Association (APA) the largest professional organization for psychiatrists still supports collaborative care - a managed care model of psychiatric care that in some cases eliminates any direct access to psychiatrists. The American Medical Association also seems managed care friendly largely due to their support of the PPACA. Both organizations support the onerous recertification process mandated by the American Board of Medical Specialties.
The only bright spot I can think of this year was being seated at the same table with 3 younger colleagues at at a Minnesota Psychiatric Society CME event. They had all been practicing for 10 years or less. They were all in private practice to one degree or another. They were all women and although I haven't seen it studied I think that women may have a greater skill level (at least relative to men of my generation) in setting up and managing a private practice. I was quite interested in their experiences and they listed all of the positives. The overwhelming positive that I took away from that meeting was that their practice environment was very positive because they ran it and had eliminated all of the toxic administrators along the way who were supposed to manage them. They did not have to tolerate the notion that just because they were an employee that they suddenly needed supervision from somebody who was not qualified to supervise them. Near the end of our conversation they tried to talk me into going into private practice myself. I have always been an employee, but my current vocational trajectory has been predicated on fleeing toxic administrators. I gave the usual excuses about being one bad cold away from retirement and an old dog not being able to learn new tricks.
If I was starting out today - I would only be working for myself and I would try to design the practice to reflect my interests in neuropsychiatry and severe mental illnesses. Any resident reading this should consider this career path. The decision may be as easy as contemplating seeing 75-100 patients a day and meeting with an administrator who suggests that you could see more.
Happy Labor Day to any physician reading this whether you are in private practice or on the assembly line in a clinic or hospital somewhere. And good luck to physicians everywhere in avoiding unnecessary administration.
George Dawson, MD, DFAPA
Kathy Pretz. Better Health Care Through Data. The Institute September 2014. p 6 - 7.