COLUMNISTS

Doctors cry, too. Our broken health care system hurts physicians and patients alike.

Established doctors are seeking ways to leave the clinical practice of medicine, and medical students are increasingly choosing not to enter primary care.

Dr. Rebekah Bernard
Physicians for Patient Protection

Social media and news sites are filled with headlines expressing discontent about the health care system, particularly a sense that doctors don't listen and don't care.

Reading these articles hurts my heart because, as a physician, I know doctors do care deeply. But a broken health care system has turned us into assembly-line "providers" and data-entry clerks without time to show the empathy that we feel and that our patients need.

The problem began in 2009, when the U.S. Health IT Policy Committee recommended that physicians be required to use electronic health records to be paid for medical services, mandating specific "meaningful use" criteria. If physicians don't address certain data points at every office visit, they get paid less.

What really matters to patients

In theory, this documentation burden was created to improve patient care, but the required data isn't always relevant to the visit and takes time away from asking the questions that matter to patients.

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Another mandate was computerized physician order entry, which requires physicians to enter orders on a computer. Each order must be tied to a multidigit diagnostic code, and simply choosing the correct code can take four to five clicks of a computer mouse. The entire process takes much more time than simply writing an order in a paper chart.

The government implemented new physician "report cards." Doctors would now be graded and paid (or not) based on our compliance with "quality measures." Failure to address these parameters at every office visit would result in financial penalties that could close a practice down.

Computerized physician order entry takes much more time than simply writing an order in a paper chart.

The result: Patients now find themselves interacting with a doctor who is serving two masters, with attention divided between their patient and their computer screen. Rather than spending most of the visit focused on the actual problem, patients are barraged by a series of questions from an electronic template and spend time discussing the risks and benefits of treatments and tests that might not even be appropriate for them.

Even worse, as physicians were encouraged to delegate more and more responsibilities, patients often found themselves talking not to the physician but to a team member working "at the top of their license."

What really matters to physicians

This documentation burden is creating problems for physicians as well. When you ask physicians what they like best about medicine, two answers top the list: "knowing that I’m making the world a better place" and "relationships with patients." 

No physician enters medicine – and certainly not primary care – with the intention of spending seven-10 minutes per patient, followed by hours clicking boxes in a computer. But government-mandated documentation requirements force physicians to choose between providing compassionate care for patients and serving a broken health care system.

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This impossible situation creates a cognitive dissonance that has been described as "moral injury" – 20% of physicians now report symptoms of clinical depression, and 13% have contemplated suicide, with suicidal thinking associated with high workload and medical errors.

Established doctors are seeking ways to leave the clinical practice of medicine, and medical students are increasingly choosing not to enter primary care in favor of specialty fields. The toll on primary care should be especially concerning to all Americans: Having more primary care physicians is associated with longer life expectancy.

How has the health care system responded? The logical response would be to change the documentation requirement and look at factors that improve patient care. Unfortunately, this has not been the case.

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When computerized physician order entry was identified in 2016 as an independent risk factor for burnout, the requirement was lifted by Medicare.

Nonetheless, it remains a requirement for Medicaid incentive payments, and most hospitals continue to require its use as a matter of institutional policy.

No physician enters medicine with the intention of spending just 7-10 minutes per patient, followed by hours clicking boxes in a computer. But government-mandated documentation requirements force physicians to choose between providing compassionate care for patients and serving a broken health care system.

Rather than rethinking this problematic policy, health consultants blame doctors, accusing us of not having a "growth mindset" and urging us to simply "rethink our workflows." Doctors aren't in a great position to push back. Health care administrators have been known to fire physicians who raise concerns, rather than change the system. 

Decrease physician burden

Administrators have enacted other policies that are actively detrimental to patient care. With highly trained physicians in short supply, they have started delegating patient care to other health care providers. While these team members can be a valuable component of a physician-led health care team, they do not have the training to take charge of a patient’s care independently.

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It is time for policy experts and patient advocates to use their political influence to advocate for systemic changes that decrease physician burden and incentivize a return to the true physician-patient relationship.

In the meantime, some doctors are taking matters into their own hands. Fed up with a lack of response to pleas for systemic change, many are turning to alternate practice models like direct primary care. Distinct from concierge care, direct care eliminates third-party payers (and their burdensome requirements), allowing patients more quality time with their own physician, and has even been shown to reduce health care costs.

Patients who are seeking a return to a true physician-patient relationship with a doctor who has the time to really listen should consider seeking such a practice.

Rebekah Bernard, MD, a family physician practicing in southwest Florida, is president of Physicians for Patient Protection and author of "How to Be a Rock Star Doctor."

The only cure for our broken health care system is to allow doctors to return our focus to where it belongs: on our patients. Until then, physicians and patients will suffer.

Rebekah Bernard, MD, a family physician practicing in southwest Florida, is president of Physicians for Patient Protection and author of "How to Be a Rock Star Doctor." Follow her on Twitter: @rebekah_bernard