The Trouble with Physician Email

There are many articles on why physicians won't use email to communicate with patients, such as the lack of remuneration, liability fears, HIPAA concerns and time constraints[1,2,3]. The fact is, physicians don't read their email or respond to anyone. Seriously. Here's a typical scenario: as physician champion for the EHR in our local system I hold once monthly sessions to trade tips & tricks and answer questions. Doctors rarely show up. Recently one of the physicians emailed me a recommendation that he thought would be of benefit to the providers (I was excited to get an email from him). "Why don't you hold a monthly tip & trick session and everyone could share?" Wow. What a great idea. How come I never thought of that? After seething for a good five minutes I sent back an email and said "I've been offering this for almost a year now. Obviously I'm not communicating it well enough to the doctors since the email announcement several days before each session isn't working. Do you have any suggestions on how to improve my communication?" The returned response was, "I guess I don't read my emails very often." You think?

The same week my manager got an email from our PR department requesting her to tell me something. When I inquired as to why they didn't send the email directly to me their response was "Because doctors never read their emails." Fair enough. But I do. 

Yes, writing this rant in a blog is singing to the choir. If you read blogs I'll bet you keep your email correspondence up-to-date, but seriously doctors: YOU HAVE TO READ YOUR EMAILS in this day and age. It is part of your job. To those of you who are tasked to communicate with physicians, even if they don't read their emails, it is your job to send them. Don't remove responsibility from the doctors' shoulders by never sending the information to begin with. You can copy the manager but you still have to email the doctor.

Our inboxes are crammed full of unimportant things so get the friendly IT guy to create filters for you. Fewer irrelevant things will be delivered to your inbox. Don't feel the need to respond to every email. Most people don't need to be thanked or even acknowledged, and they don't want more extraneous emails in their inbox either. Establish a "throw away" email address on Google or elsewhere to give out when you buy something. Unsubscribe to sites that send you stuff. For more in-depth writing on the subject I recommend the Asian Efficiency website, especially this guide on emails.

OK, back to my inbox. There is probably some mail I need to respond to.

1. Weill Cornell Medical College. The Doctor Will Email You Now
2. http://healthecommunications.wordpress.com/2011/07/19/lack-of-time-and-reimbursement-is-that-why-physicians-dont-do-a-better-job-communicating-with-patients/
3. Wall Street Journal January 23, 2012  Should Physicians Use email to Communicate with their Patients? http://online.wsj.com/article/SB10001424052970204124204577152860059245028.html

A * Readable * Usable * Patient Note

It's not just the clicks. It's creating a Readable.Usable.Note.[1][2] It is embarrassing to look at a patient chart and read: "Your HDL (good) cholesterol is excellent but your LDL (bad) cholesterol is too high. I would recommend trying to reduce sure fact food intake." What? Oh, yeah, reduce your fatty food intake. Or worse: "She wanted me to know that she had a laparoscopic hysterectomy and in for reck to me over the summer." That one took a while to figure out. What I dictated was "she had a laparoscopic hysterectomy and oopherectomy over the summer." Ouch. I read over my notes before I sign them but between the rush of seeing patients and the problem with editing your own notes within the horrible output that electronic records produce, it's easy to miss your own mistakes.

The notes are built to maximize the billing that we do. But frankly, even though I revisit a patient's chart and check their past medical history, update their meds, update their family history, review their social history, etc. IT DOESN'T NEED TO BE REPEATED IN THE NOTE! However, if I don't rewrite all that, Medicare or the insurance company doesn't believe I did it and I can't charge for it. As a consequence everything is repetitive and finding the little gem of information one needs to care for the patient becomes more and more difficult. As anyone who has ever received the reams and reams of paper from an ER with an electronic health record (EHR) that has no discernible font changes or indentation can tell you, it is next to impossible to determine why the patient was there, what treatment they received and what followup they need. 

To counteract this I dictate my medical reasoning in the discussion box at the end of the note. Next visit that's where to look to find the important stuff. Of course this increases the amount of time documenting, taking away more precious moments I have to spend with the patient creating inelegant notes that are one step away from being worthless for subsequent treatment.  

What if we could create two notes for every patient. One that went in to the billing records for auditing purposes and one culling the important stuff into a true "patient care note". Surely there is software that could help us with that.

To quote Dr. Vartabedian: What do you think?

1. We need to reassess the patient note. http://www.kevinmd.com/blog/2013/08/reassess-patient-note.html
2. The doctor will see your medical record now. http://www.slate.com/blogs/future_tense/2013/08/05/study_reveals_doctors_are_spending_even_less_time_with_patients.html

The Importance of Being on the Same Page

No doctor is perfect. My guess is that orthopedic surgeons are as tired of talking about the importance of weight loss and exercise as I am to what seems to be deaf ears. Worse, it's unprofessional to complain about other specialists[1], but my last two weeks have been a bit frustrating. 

• Patient was seen two years ago with "mild arthritis" in a joint. She was told by two orthopedic specialists that she didn't need surgery. Neither of them recommended physical therapy or for that matter, any movement whatsoever. Apparently that's what she didn't do--move (or so I've been told by a friend). Now she's scheduled for a joint replacement having never been offered the option of physical therapy. I cannot help but think her inactivity accelerated her joint problem.[2]
• I encourage my patients with knee and hip pain to exercise and especially to lose weight. If I send them to an orthopedist they come back to me and deny that the orthopedist recommended weight loss. I think they just didn't hear what they don't want to hear but many times, there is nothing in the referral note indicating that they were told to lose weight. 
• Last week two patients came to me after they saw their orthopedic surgeons asking ME to send them to physical therapy. Why? Because the surgeon didn't recommend it. 

Several years ago a friend of mine was sitting in an orthopedist office. After looking around the orthopedic's waiting room, she began a diet and exercise program the next morning. She told me "Except for the athletes, every person over 50 in that office was at least 30 pounds overweight. How can you miss the message there?" At that time she was in her early forties. Now ten years later she has kept the 10 pounds she shed off and exercises at least four times weekly.

Day in and day out I understand how frustrating it is to try to motivate patients to exercise and lose weight. Many of my orthopedic colleagues DO emphasize these things and my sense is that they are improving in that regard. In a society where obesity is ever more the norm, we've all got to be on the same page to help patients make changes, especially if you are the expert in the patient's eyes.[3] 

1. http://well.blogs.nytimes.com/2013/07/11/doctors-badmouthing-other-doctors/

2. http://www.mayoclinic.com/health/arthritis/AR00009
3. http://www.news-medical.net/news/20130411/Orthopaedic-surgeons-should-recommend-weight-loss-to-patients-prior-to-joint-replacement.aspx