Physicians, paperwork, and paying attention to patients

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Have you noticed that when you go to a doctor's office, the providers are on a computer or flipping through papers for much of the visit? Maybe they're looking through your records, typing your history, filling out forms, or checking boxes from a questionnaire. Whatever it is, isn't it kind of weird and awkward that you're sitting there in person for an illness or an examination, and you are not the primary focus of attention?

Just how much of your visit do we spend on "overhead"? A lot.

In fact, you're not imagining things, and it is weird and awkward. A recent study published in the Annals of Internal Medicine supports prior research in this area showing that a ridiculous amount of a doctor's time is spent interfacing with a computer or on other administrative tasks, instead of with patients, even when the patient is right there in the room.

The researchers observed 57 physicians from four different specialties (family practice, internal medicine, cardiology, orthopedics) in four different states for a total of 430 hours. They were interested in learning precisely how doctors spend their time.

What they learned was that during office hours, half the time — a huge chunk — was allocated to desk work, like documentation in the electronic medical record (EMR), reviewing test results, handling medication requests, and filling out forms. What was remarkable was that even during office visits, doctors interacted with their patients for only half of the time; the rest was EMR and paperwork. As a matter of fact, for every hour of face-to-face patient time, another two hours were spent on desk work.

Notably, about 40% of the doctors observed in this study used documentation support, like voice recognition software or medical scribes, and they still got these results. Also notably, none of the primary care doctors had the luxury of documentation support. You can imagine that the family practice and internal medicine docs (like yours truly) spend even more time on desk work.

So, when you felt that your provider wasn't paying attention to you for much of your recent visit, you were right. And you know what? We hate it, too.

What exactly are we doing when futzing with papers or computers?

It's no revelation that physicians in all specialties are feeling increasingly bogged down with the desk work. But what does "desk work" mean? Well, let me tell you.

Let's say you're just in for a physical. During your 20 minutes, I have to catch up on anything that's happened since your last visit, review and update your medications, listen to any current ailments that you'd like addressed, and answer your questions from the list you brought. I need to make sure I'm not missing anything you might be due for, like vaccinations, bone density, or cancer screening tests (Pap smears, mammograms, colonoscopies). We may need to discuss screening for sexually transmitted diseases, and birth control. I may also need to review your specialists' notes and recommendations. I have to examine you, which can include paying special attention to your areas of complaints, like that rash, or a swollen knee. I need to note any previous abnormal test results, then discuss and order labs. For these and any other tests, I have to fuss with our high-tech electronic system to match an acceptable diagnosis with the order, or your insurance may not pay. Before you leave I need to make sure you understand any new prescriptions or treatment plans, and that you're all set with your medication refills. Often, people also bring forms they need filled out, like those work health status checklists, family medical leave paperwork, or preoperative requirements.

And here's what we do after you leave

After your visit, I need to follow up on your test results and report them to you. I know that if there is something abnormal you'd rather hear it from me, and personally, I'd rather be the one to call you. But I have to allocate things like high cholesterol and osteopenia (reduced bone density) to my nurse. I try to speak to patients directly about positive tests for sexually transmitted infections or other potentially unsettling results. Regardless, I type up the lab interpretation and plan and send it to you in writing.

If we referred you to a specialist and you're having difficulty getting an appointment, I can sometimes intervene and try to speed up the process. I'll write to the specialist and explain the issue, which involves reviewing your chart and summarizing the issue as concisely as possible. Or, more and more frequently, we'll make it an "electronic consult," where the specialist relies on my history, exam, and testing, reviews your case, and provides guidance on your issue to me directly, without seeing you. Then, I need to follow up on his or her recommendations and communicate everything to you.

Often insurance creates major tangles and snafus. For example, it can require an unbelievable amount of time and effort to have an MRI or a sleep study approved, never mind replace a broken CPAP machine (I have a good story on that!) And I haven't even mentioned school physicals, letters of medical necessity, and disability forms. I could go on and on, and I have.

No, I'm not leaving primary care anytime soon. But I do want patients to understand that yes, we do spend an inordinate amount of time not paying direct attention to them, and yes, we hate it too.