Friday, July 10, 2009

Physician Culture - Observations after Three Private Doctor Visits

This week as a patient I visited three doctors – a cardiologist, a dermatologist, and an ophthalmologist. The cardiologist was in a group of eight, the dermatologist in a group of two, and the ophthalmologist practiced solo but was part of an eye surgery center founded by a number of ophthalmologists.

As part of my visit, I carried a copy of my book Obama, Doctors, and Health Reform as a spark for reform discussion. The book led to lively discussions about reform in general and about specific reform recommendations of others. These recommendations included eliminating fee-for-service, decreasing the number of specialists, and use of electronic records to facilitate care, affords diagnostic support, and decrease waste.

Not surprisingly, was their agreement that ending fee-for-service was an impractical fantasy, that mandatory electronic medical records were overkill and would do little to improve care, and that shortage of doctors in their specialties was imminent. None of these specialists had an electronic medical record system. The cardiologist thought such a system was inevitable but greeted the idea with a notable lack of enthusiasm. The dermatologist and ophthalmologist said installing EMRs in their practices made no sense, and added it would be cheaper to take a penalty rather than install a system.

All shared the opinion that a centralized command and control system could not possibly control all the variables, permutations, and combinations of patient-doctor interactions that went into decision making on the part of patients and doctors. Most thought a centralized government-run system would continue to decrease reimbursement and would lead to rationing.

All were fatalistic about decisions made in Washington, and all doubted any federally-directed system would improve care on the ground. Most thought Medicare fee reductions were likely but were arbitrary and capricious and had little relation with their cost of doing business. All, however, said they would continue to see and accept new Medicare patients, even if Medicare reimbursement did not cover their costs.

This is a small, perhaps even a meaningless and certainly not a statistically significant sample, but it is relevant to the current debate. In my option, it reflects a general resistance and skepticism about federal intervention. Among doctors, there are no miracles among friends, and no expectations of silver bullets being fired from Washington. These physicians have a free market mindset - an intricate voluntary system of economic, social, and cultural interaction representing desires and needs of individual patients and doctors.


Glenn Laffel, MD, PhD said...

It's disheartening, though not surprising to hear that some specialists' hold negative views of EMRs, since so much of providers' collective experience with EMRs is derived from their travails with legacy, client-server based systems. This technology was developed in the 80s and 90s and is not particularly well-suited to fast-paced specialty care.

Practice Fusion ( offers a Web-based EMR to physicians for FREE. We are growing rapidly and thousands of specialists are using our system.

In fact, physicians who sign up are often charting the very same day.

Now that EMR technology has advanced to a point where it can meet the needs of busy physicians,it is our hope that more and more of them will agree that the technology can now begin to fulfill its potential as a quality-improving, cost-reducing, productivity-enhancing tool.

That is what President Obama and his staff believes, and that is what we believe as well.

Glenn Laffel, MD, PhD.
Sr. VP Clinical Affairs
Practice Fusion
Free, Web-based EMR

John said...

This is an important observation. You have put your finger on the biggest obstacle of all to reform, embedded resistance to change. REALLY embedded.

Tonight I took a dvd back to the "Red Box" for one of my children. (
These places rent dvd movies for a dollar a day. They are state of the art vending machines that only take credit cards. Video rental places are now officially obsolete. The technology is breathtaking. Blockbuster and Hollywood Video rentals will remain for a few more years, along with the growing number of rental stations in grocery stores and other locations. But the handwriting is on the wall. Theirs is a vanishing species.

In my post-post-retirement life I work as a caregiver for (other) seniors. One of my assignments was in a skilled nursing facility where I saw a CNA operate a touch screen console during her shift. She was moving through the screen prompts like a kid with a video game. In a few minutes she documented enough information about five or six residents that would print out to at least a page or two each. It's not likely that much of what she entered will ever be printed or retrieved, but I can assure you that if any disgruntled family member or reward-seeking lawyer wants to bring any complaints to that facility they better have all their ducks in a row because the record I saw being created will be air-tight. (And in the unlikely event that a physician actually wants to know anything, the information will be easy to access, plainly presented and dated.)

These two examples illustrate a sad but real challenge. Technology is here, like it or not, and the future will be built on that technology. There will be fits and starts and unintended consequences along the way. It may be necessary to rear, train and employ an entire new generation of physicians who "get it." But it is going to happen, with or without the approval or acceptance of those standing in the way.

There is a message from the military here for those who cannot see the future: Lead, follow or get out of the way.

Not to put too fine a point on it, but health cared as it stands is no coherent system at all. It presents wildly uneven outcomes, costs and disparity of access. For millions of Americans all the fits, starts and unintended consequences imaginable cannot be any worse than staying the course.