To play doctor, a child used to need a plastic stethoscope and a little black bag with some Band-Aids inside. Now she needs a tablet to access her patient’s electronic medical record—and odds are, she’s gonna be late for dinner.
We talked to a handful of highly respected internists, all of whom said that electronic recordkeeping systems add between 90 minutes and two hours to their days. They’re losing autonomy to Big Pharma and Big Insurance. And they’re worried that younger physicians won’t choose primary care anymore—why work longer, less predictable hours for less money and less latitude?
Your guide to a healthier, happier you
Sign up for the St. Louis Wellness newsletter and get practical tips for a balanced, healthy life in St. Louis.
“In the U.S., there are far more specialists than generalists,” notes Dr. William Birenbaum, who works with BJC Medical Group and is affiliated with Missouri Baptist and St. Luke’s hospitals. “In other countries, it’s the opposite, which is what you need. But people come out of med school with huge debt…” So they choose a lucrative specialty, and it becomes harder and harder to find a primary care physician.
After offering a few examples, Dr. Bari Golub says, dryly, “Who’s going to take care of me?” She’s only half joking.
TMI?
“If I had a magic wand, I’d put a transmitter in my brain so whatever I was thinking would go directly to the electronic record,” says Dr. Simeon Prager, who belongs to the SSM Health Medical Group. He’s tried voice-to-text, but it still produces “some pretty funny errors.” And every detail of an individual’s care must go into that shared, standardized electronic record.
Information gets dumped, says Golub, also part of SSM Health Medical Group: “You’ll open it and see a lab result but with no context, and there are tons of entries, and you have no idea what’s in them until you open them.”
“The primary care doctors have to maintain the record,” explains Birenbaum. “It falls in our laps to make sure the diagnoses and medications are correct.” A big chunk of each patient appointment is just getting up to speed, sifting through data to find what used to be visible in a few seconds of thumbing through notes. And there are thousands and thousands of very specific diagnosis codes, so just finding those takes time. Essentially, he says, physicians are “helping the insurance companies with data entry! There’s so much information, much of it trivial things the secretaries have already taken care of. I get all these computer-generated notes from specialists, five to seven pages, every medicine they took for the past two years, but to find an actual meaningful sentence is difficult. And I think it creates more errors, to be honest with you: Everybody’s got their fingers in, so to speak; all sorts of people are feeding data into that record.”
Golub agrees that “a lot of junk gets blown into the specialists’ notes,” which are turned into long-winded prose by the computer. “You have to scroll and scroll and scroll. The system definitely can improve treatment if it’s used properly; it can track data, and it has the potential to improve outcomes. But you talk about physician burnout! The EMR’s the No. 1 cause.”
No point in resisting, says Dr. Angela Brown with a shrug: “We’re locked into it. And it is nice to have all the patient’s information right in front of you; you get a much more complete picture.” Brown, a clinical hypertension specialist at Washington University School of Medicine, is taking a class to learn more filters and shortcuts, but still she worries that communication is getting shortchanged.
“With paper notes, my nurse and I would sit down and go through everything. Now, we don’t have to talk; it’s all in the electronic record. But she knew how I thought; she could say, ‘Dr. Brown is going to want to know X.’ There’s an educational loss, and there’s a loss of team-building.”
Telemedicine and Big Pharma
Telemedicine’s another frontier, offering care to patients in remote areas. Brown is grateful for the ability to track, year-round, the vital signs of patients who live in southern Missouri or Illinois. But she has caveats: “If a patient is complaining of swelling in their ankles, I need to be able to see that. Listening to the heart and lungs, examining the extremities and the blood vessels—sometimes a picture doesn’t capture what you need.”
Physicians use our smells, the color of our nail beds, the clamminess of our skin to make subtle diagnoses. “You can put your fingers under the part of the chest wall and see how hard the heart is banging and whether it’s laterally displaced,” says Prager. “With high blood pressure, it’s pushed off to the side.” Telemedicine “will get some people into care who wouldn’t be otherwise,” he says, “but touch is part of the therapeutic alliance. It’s reassuring. We have all these diagnostic tools, but you lose a lot if you’re not observing in person.”
“You develop a sense,” agrees Birenbaum. “The other day, a nurse practitioner examined someone, and then I opened the door and, just by looking at him, I could tell that he needed to get to the hospital. It was a perforated appendix.”
Birenbaum’s other frustration is Big Pharma and “the profits they generate from generic meds that literally cost a penny a pill a year ago. Some drugs in Europe are a tenth of their cost here.” There has to be a better way to foot the bill for developing new drugs, he says. “Even though we spend so much more per capita here in the U.S., when you look at the rankings for our health, we’re not even in the top 20 or 30 countries.”
Still, breakthroughs can be miraculous. Prager’s been treating patients with HIV since the ’90s, when it seemed such a death sentence that one physician actually asked him why he bothered. Now, thanks to drug advances, patients with HIV are living full lives and dying of other causes. “Big Pharma doesn’t have a great track record, though,” he continues. About five or six years ago, he recalls, a pharmaceutical company raised the price of a drug about 600 percent. “It had originally been prescribed at a very high dose that made people really sick, and then it was reborn, because they figured out that using really tiny doses boosted other HIV drugs and made them valuable—and then they raised the price! You see stuff like that and just scratch your head.”
Golub is seeing changes in her patients’ compliance as drug costs rise: “Insulin’s one of the costliest medicines. Inhalers can cost hundreds of dollars. And we get insurance companies meddling in generic proven medicines, saying we can’t use them. We are definitely a profession that’s not being run by the professionals.”
The Painkiller Pendulum
A young woman who suffers horrific migraines recently moved to St. Louis. She says she was first prescribed Vicodin at a far higher dosage and quantity than she’d received in Colorado, then was denied any and passed back among various specialists like a hot potato—and when she called urgent care, in pain and in tears, she says she was told to take an Advil. Are we, in our panic over opioids, swinging too far in the other direction?
“A lot of patients get true benefits from these medicines,” says Birenbaum, “but a lot of docs won’t prescribe them now. Pain management doctors will give you an injection and say, ‘If you need medicine, go to your primary care doc.’ I saw a woman today, 85 years old, terrible back and knee pain, so she takes two or three Vicodin a day, and now she feels like she’s a criminal.
“We try all the other medicines first,” he notes, “but some people need the opioids. In the early ’90s, nobody took any of these meds, and then we were told, ‘You’re not treating people’s pain. Don’t be afraid to prescribe painkillers.’ So we started using them for chronic pain, and it helped. And then the people who started abusing them filtered in and created kind of a mess. But if they are well managed, they can be helpful.”
What Golub can’t fathom is why Missouri is “the only state that does not have a universal pain med registry,” which could help distinguish valid use from abuse. Opponents have declared it a privacy issue.
Relationship Problems
“The times you’re actually practicing medicine, it is still deeply satisfying,” says Golub, “but at least three-fourths of what you’re doing is not hands-on with the patient.” And the patient-physician relationship is changing: “Patients jump from one physician to another as their insurance changes. They are educated by the internet, so they don’t necessarily believe you. And they’re sicker: People are living longer, but there are more chronic illnesses, more multiple diagnoses, more mental health issues.”
Prager has just come from seeing a patient who may have diabetes but didn’t want his blood sugar tested. “He said, ‘My insurance doesn’t cover bloodwork very well anymore.’ And some laboratories won’t do bloodwork if the patient owes as little as $10 from a previous blood draw.”
Patients have told Brown, who now focuses her practice entirely on hypertension, that they no longer like to go to the doctor. “You have to be really careful to look at the patient, not just your screen,” she says, “or it’s easy for them to get the impression that you are so busy on the computer and you’re not paying attention to them.”
Some of today’s frustrations originate with patients themselves: They discontinue meds because they read something wild online, or they see a commercial and decide that testosterone shots will reinvent their life. “They say they exercise, and it’s walking to their boss’ office 20 times a day!” Brown says. “Some people have actually told me that taking a pill is easier. We live in a hustle-and-bustle society. It’s easy to eat out, to eat fast or processed food.”
“And just the stress,” groans Birenbaum. “In Denmark, if you’re at work at 5, they say, ‘What are you doing here?’ We say, ‘You’re going home?’”
Despite all the obstacles, though, Birenbaum wouldn’t dream of leaving. “There’s nothing else I’d rather do,” he says. “Nothing makes you feel better than seeing someone who is really sick get better.”
