Posted on Primary Care Progress (primarycareprogress.org/blogs/16/334) in mid-January 2014. An original shorter version titled 'The accelerating pace' was published in early January as the Medical Column of the British Society Newsletter, Montevideo, Uruguay.
Thanks to Sonya Collins from Primary Care Progress for editing the post.
I passed the 60 mark more than a year ago and since then have been more aware of my limitations; some joint aches, getting tired easier, more need to rest and longing for a slower pace in my everyday routine. Meanwhile, general medical practice is speeding up and increasingly shedding its limitations. As information expands exponentially, doctors need not only to keep up with the information that reaches them directly, but also the information patients bring to them via Internet and other consumer sources. Present-day communications have not only expanded both patients’ and clinicians’ access to information, but they have also made the in-person office visit just one of many ways of interacting and have put patient information a mere keystroke or mouse click away. It seems that all in one day, I am practicing many modes of medicine besides the traditional face-to-face consultation – either all at the same time or in rapid succession. At a stage in my professional life when the distance I see in the rear view mirror is a lot further than what I perceive through the windshield, I am adapting to the accelerated pace that is imposed on all of us.
Immediate access to information means waiting is equated with time wasted. If the information is available instantly, we wonder, why wait to make a decision about it? All of us – patients, physicians, consultants, laboratories, diagnostic and treatment services – interact in modes that are expected not only to be instant or immediate, but also reliable and of high quality. Expectations are continuously ratcheted up and the pressure to perform to the changing standards is ever-present. In this new milieu, many of those involved resist the changes. Some patients stick to the old-style office visit or phone call; many physicians do not use messaging or emails and even request to see their patients to refill chronic medications or check on test results. We still have laboratories requesting that results be picked up or at best faxed rather than provided securely online. Although some of the resistance can be attributed to legal concerns and lack of reimbursement in a fee-for-service environment, most of the resistance stems from the uncertainties posed by these changes. But this inevitable change will force us all to adapt and write history or be part of it.
In this final lap of my medical career, I have decided to jump onto the bandwagon. I have used email to interact with my patients for the last sixteen years. In Uruguay, where I practice, we don’t have an equivalent to HIPAA to present any barrier to emailing. So I make sure that the patient is as familiar with the limitations of email as I am. They must know that email is at best a “warm line,” never a hotline. (I’ll never forget a patient who sent successive emails every half-hour from 4 a.m. describing symptoms of ascending polyneuritis until he could barely tap the keyboard anymore!) And if something too sensitive becomes part of the email conversation, I recommend a face-to-face visit to sort it out. Ultimately, a patient who emails values access more than potential privacy leaks.
I try to avoid face-to-face interaction for returning test results or medication refill requests for stable and controlled patients. During my workday, I have input from five sources: standard phone, cell phone, texting, email, and messaging embedded into the electronic health record. We’re not reimbursed for time spent in these other modes of communication. I simply do it for the added value I believe we should be providing by not overusing or overbooking our face-to-face agendas, which I try to reserve for what they’re most useful: eye-to-eye contact, body language, voice, and meaningful silences. I book my patients every 25 minutes – four consecutive 20-minute slots and a fifth slot blocked in case I run over. I could be making more money in 15-minute, one-size-fits-all slots and cut out the multimodal communication, but at this stage in my medical life, I'd hate to still be practicing late-20th-century general medicine.
As of last July, I'm the oldest of the practicing generalists in the outpatient center, and I want to be a role model for my younger colleagues, many of whom were brought to the practice more than a decade ago, when I was its medical director. That's why I won't jump off the bandwagon.
With this added value in place, it’s probably going to be easier to negotiate payment reform for generalists because we can readily document the amount of time it takes to do the non-visit work. In my case, it takes about one hour or more of my workday.
Does this feel like an accelerated pace and a crammed agenda? You bet! But I have the satisfaction of finishing today's work today and using face-to-face interaction for those problems to which it is best suited. The buzzword is “accessibility”: minimal waste of mine and my patients' time, with time-use tailored to patients’ specific needs. Am I overwhelmed with work and overwork? Yes, sometimes, but mostly during normal work hours. Ready accessibility during work hours is coupled with very low or minimal requests outside work hours.
Primary care has to go multimedia. There’s no space or time left for continuing with the post-WWII assembly-line model. Either we transform ourselves as providers, or outside bench-sitting regulators who know little of what happens in the real world will do the job for us. At a time when many are mourning the lost times of good old practice patterns, I am enjoying my small share of what the future will bring in interactions between patients and their health care providers. Yes, the pace is accelerating more and more, but like Moses on mount Nebo, I'd like to see the Promised Land at least from afar when my time to retire comes.
Jorge Stanham, M.D., practices internal medicine in Montevideo, Uruguay, and holds certifications in public health, existential analysis and logotherapy. He has been on faculty at Facultad de Medicina, Universidad de la República. He was medical director at British Hospital Montevideo Uruguay, where he is now medical advisor. His interests are primary care, electronic health records, communities of practice, existential philosophy and theological reformulation for a post-modern 21st-century society.