The 21st Century Patient-Physician Relationship

You can probably sympathize with the worry and anxiety your colleagues felt following the invention and rapid adoption of the telephone in the late 1800s. For them, this new device sparked concern and debate, raising new questions regarding their duties to their patients. Would the easy access promised by phone service prompt patients to make increased demands on physicians’ time? If so, what obligations did physicians owe to patients calling at all hours of the night? Was it ethical to conduct a medical consultation over the phone? Would answering the phone and briefl y talking with a patient necessarily establish a relationship, making the physicians duty bound to provide continuing care? Would resorting to telephone-based communication depersonalize the historical personal bond between physicians and their patients?

Today, physicians and patients are wrestling with the changes wrought by new, more powerful technologies and are seeking answers to many of the same kinds of questions regarding the physician— patient relationship that confronted their 19th century forebears. Communication between physicians and patients nowadays is near instantaneous and can be conducted in a bewildering variety of formats: telephone, fax, e-mail, voicemail, video conferencing, and instant messaging. Patients grown accustomed to 24/7 customer service in their other personal and business transactions (especially those conducted online) are increasingly demanding the same level of access to and responsiveness from their healthcare providers. Physicians are struggling to keep up with the demand, but must weigh their desires to be available to their patients against questions regarding reimbursement for time spent, privacy issues, and liability concerns.

Patients are also demanding more convenience and flexibility from physician practices when it comes to setting up appointments, requesting medication refills, obtaining test results, and other services. In the past, patients had to rely solely on the discretion and timetable of their healthcare providers, but now, thanks to the availability of practice websites featuring applications that enable online appointment scheduling and prescription refill ordering, patients are growing accustomed to on-demand service from healthcare providers.

You Have Mail, But Not From Your Patients

So what gives? Drop us a line at ccole@mdng.com and share your opinions on physician—patient e-mail communication.

But perhaps the most profound change to the patient—physician relationship has come about due to patients’ ability to quickly access healthcare information. In the past, patients who desired to read clinical medical information required access to a medical library. Even then, the process of uncovering relevant data was laborious, time consuming, and isolated. The only interactive part of the process involved asking a librarian how to use the microfische. Nowadays the Internet enables rapid access to even the most obscure clinical journals, not to mention dozens of user-friendly sites that distill and interpret that information, leading to the advent of new terms to describe patients and their attitudes and roles vis-à-vis healthcare delivery: “informed,” “active participant,” “empowered.”

And thus, the patient—physician relationship continues to evolve, with technology playing an ever-greater role in driving the changes. From how patients and providers communicate between office visits to how patients interact with their providers during an exam, from the services patients expect from practices to the ways in which patients search for, internalize, and act on medical information, healthcare information technology is altering the physician–patient relationship in ways great and small.

Inboxes Are In, Sort Of

We began our discussion by recounting how the introduction of a new communication technology altered the patient—physician relationship. Just as with the telephone more than a century ago, e-mail is a form of communication that was slowly adopted at first but then later became ubiquitous and is changing the ways in which patients and their physicians interact. When it comes to the use of interactive communications technology in practice, physicians have definitely been slow to meet their patients’ demands when it comes to the use of e-mail. It seems like we’ve been talking about physician-patient e-mail for years in the pages of MDNG. Everybody uses e-mail in just about every other area of their professional and personal lives, but for a variety of reasons (stop us if you’ve heard these: concerns over the privacy and confidentiality of potentially sensitive personal information contained in e-mails; fears that patients would flood doctors’ in-boxes with inappropriate requests, questions, and comments; lack of reimbursement for the time physicians spend answering e-mail queries) this form of communicating with patients has not caught on with physicians. A survey conducted last year by the Center for Studying Health System Change found that only 24% of physicians surveyed reported using e-mail to communicate with patients in 2004-2005. Contrast that figure with the 80% (80%!!) of patients who told a Harris Interactive Health Care Poll in March 2005 that they would like to communicate with their physicians using e-mail. The relatively small percentage of physicians who have taken the plunge and allowed e-mail communication with patients have reported mostly positive results. The asynchronous nature of e-mail is particularly suited to non-urgent healthcare requests and questions, and patients have been remarkably circumspect in their volume of correspondence. Although physicians’ increased availability via e-mail is no doubt appreciated by patients and the source of no small amount of goodwill, there is another aspect to consider. With increased access comes increased expectations of access and responsiveness, adding to physicians’ burden and altering their relationship, however slightly, with their patients.

Relationships 101

Patients’ views of their roles in the flow of information regarding diagnosis, treatment, and management is changing to reflect patients’ vastly increased access to reliable medical information via the Internet. No longer content to be passive recipients of healthcare instructions dictated by providers, patients have been recast as healthcare consumers, active and equal participants in the healthcare decision-making process who have been empowered by the knowledge they have acquired through the use of information technology. This has had a profound impact on the exam room dynamic. Nowadays, people are likely to show up in your office, clutching stacks of printouts about diseases, conditions, and medications. They know what they want and they are less shy all the time about asking questions, challenging assumptions, and demanding an increased voice in their care. They’ve seen pharmaceutical ads on television; read healthcare blogs written by patients, physicians, and industry experts; chatted about their condition or complaint with other patients online in forums specifically set up to facilitate interactive healthcare discussions; and e-mailed friends and family to get their opinions and learn about their experiences. The common denominator in all of this is the Internet.

Never before have patients had such fast and ready access to information of such complexity, varying reliability, and diversity. Although nobody can seriously argue that patients should not enjoy widespread access to healthcare information, Alexander Pope’s dictum that “a little learning can be a dangerous thing” seems especially apt when it comes to online medical information. But the way in which this danger manifests has changed from a few years ago. Before the Internet became so corporatized and settled, before the advent of the current landscape of well-known, user-friendly, and reliable healthcare information websites, patients were more or less on their own, adrift in a rather wild frontier of information and disinformation. Patients, new to the whole online experience, had no benchmarks for quality and reliability when it came to what they read online. They necessarily had to rely on their physicians and other healthcare providers to vet the info they found and brought to the office visit, meaning the traditional patient—physician relationship remained more or less intact, with the physician as still the final dispenser of wisdom. But, as the Internet has matured as a conduit for information exchange, people have become more accustomed to the process of actively seeking out detailed and at times arcane medical information online. Greater demand for better online medical information has fueled the growth of new, more interactive and user-friendly health information websites (and improvements to existing sites), which in turn reinforces peoples’ positive experience with online medical searches.

This synergistic, symbiotic relationship between patients’ greater demand for a high-quality online experience and the Cambrian explosion of better sites to meet that demand has altered the patient —physician dynamic. Although it is true that there still are a great many unscrupulous websites out there that knowingly peddle false or slanted information, patients by and large are becoming more sophisticated in the selection of their sources of medical news and information. (see "Or Are They?") This has been both supported and driven by an ever-expanding roster of high-quality patient education websites such as WebMD, InteliHealth, Healthology, FamilyDoctor. org, and the like (see "Web 2.0"). As patients’ confidence in their sources of online information has increased, so too has their confidence in presenting this information to their physicians and using it to guide their healthcare decision making, sometimes in conflict with what their doctors are telling them. Anecdotal evidence indicates that the questions of Web-savvy patients are changing from “I found this online, is this true?” to “I found this online, and here’s what I want you to do.” Physicians are spending less time debunking healthcare myths and are spending more time explaining the subtle differences between two treatments or talking about the significance of new study results that their patients found on PubMed. They are increasingly required to guide their patients through an educational and research process that is largely out of the physician’s control and that just was not possible back in the days of handing out pamphlets and brochures. The power of the prescription pad means physicians are still the final arbiters of treatment decisions, but patients nowadays have the information available to allow them to have an ever greater say in what is written on that prescription pad.

Or Are They?

A survey for Pew’s Online Health Search 2006 found that only 15% of people “always” check the source and date of the health information they find online. Seventy-five percent of respondents revealed that they check the source and date of online health information “only sometimes,” “hardly ever,” or “never.” That means, according to Pew, 85 million Americans are “gathering health advice online without consistently examining the quality indicators of the information they find.” Why do you think this is? How do you explain the contradictory phenomena of the false legitimacy many people seem to ascribe to information they read online and the equally common view that “you can’t trust everything you read?” How do you handle this basic rule of health literacy with your patients? E-mail us at tkunkler@mdng.com.

Physicians Play Catchup

Patients’ increased access to reliable, easy-to-use, interactive online health information and resources has been mirrored by the explosion in dynamic and portable healthcare information technology now at physicians’ disposal. Physicians have nearly instantaneous access at the point of care to drug and formulary information (www.epocrates.com), a vast array of medical textbooks (www.skyscape.com), decision support and evidence-based medicine resources (www.uptodate.com), medical calculators (www.medcalc.com), and coding and billing support (www.mobiledesigntech.com). And that’s just through their handheld computers. When you factor in the rapidly expanding roster of comprehensive electronic health record products (more than 50 have been certified by the CCHIT; see the complete list at www.cchit.org/certified/2006/CCHIT+Certified+Products+by+Product.htm) and the burgeoning ranks of more powerful- than-ever laptops and tablet PCs on which to run them, it’s clear that physicians have the means to access more information faster during the patient encounter than ever before.

But how is this increased access to and concomitant reliance on information technology affecting the physicians’ interactions with their patients? Dr. Michael Wilkes, professor of medicine at the University of California, Davis, is concerned about EHRs’ potential to depersonalize the patient—physician encounter. Writing in the Sacramento Bee, Dr. Wilkes worries that by introducing a computer to the exam room, physicians are erecting a barrier between themselves and their patients “just as a fence divides two neighbors”—that could undermine effective communication. He acknowledges the theoretical benefi ts of EHRs (reduce medical errors, enhanced quality of care, etc., etc.), but also notes that the practice of medicine, at its heart, “involves one human listening to, talking with, and examining another” human and that anything that could potentially detrimentally affect that relationship should be approached with study and caution. If Dr. Wilkes’ fears prove to be true, then how can practitioners reconcile the definite technical benefits of EHRs with their drawbacks in the exam room? Patients and physicians both are already keenly aware of the lack of time providers have to devote to each patient visit; how will patients react to a physician who spends an inordinate amount of time in the exam room with his or her eyes glued to a computer monitor while he or she furiously clicks through screen after screen entering information? A study reported on in the March/April 2006 issue of Annals of Family Medicine sought to “determine those factors that influence the manner by which physicians use the EHR with patients and to provide a framework for considering how physicians might best use the EHR to foster therapeutic relationships with their patients.”

The authors reported that the presence of an EHR (and its associated viewing screen) in the exam room definitely influenced the interaction between physician and patient. The physical presentation of the EHR itself had an effect: “Large, fixed monitors located in the corner of the examination room caused consternation among both physicians and patients, whereas flat-screen monitors on mobile arms were universally praised.” Although the “ability to rearrange the position of the monitor changed the dynamic of encounters” by offering physicians “the opportunity to engage patients in their own medical record,” the authors note that “this flexibility was infrequently used because of a predominance of biomedically focused practice styles and a relative lack of physician interest in fostering patients’ involvement” (see The Devil Is in the Details).

Web 2.0

Consumer demand for more powerful online healthcare tools is being met by what has been termed “Web 2.0,” defined by Webopedia as describing “a second generation of the Internet that is focused on the ability for people to collaborate and share information online.” In addition to Steve Case’s much-talked-about Revolution Health, other websites that incorporate the principles and concepts of Web 2.0 (sometimes referred to as Health 2.0 in the context of online healthcare information) include OrganizedWisdom, HealthLine.com, and Vimo. All rely on interactive networking, information sharing, and open communication between patients and professionals. Check out these sites when you get a chance. Your patients definitely are.

Another behavior-modifying effect associated with EHRs noted by the authors was that the immediacy of electronic access to information aff orded by the EHRs meant that “a concomitant pressure existed for physicians to enter chart notes in the examination room,” leaving the studied physicians feeling “conflicted between recording medical information in the EHR and giving one-on-one attention to their patients.” And another determining factor in how comfortable physicians and patients were with the presence of an EHR in the exam room? The physician’s typing skills. “The simple ability to type,” noted the authors, was “crucial to using the EHR effectively with patients.” One participant went so far as to opine that a practitioner won’t be able to effectively use an EHR if he or she can only hunt-and-peck or has to constantly look at the keyboard as he or she types.

The study’s authors report still other “subtle effects on the flow of the encounter.” Namely, they noticed the tendency that, once physicians entered the exam room, they “most commonly walked straight to the monitor after only a brief greeting. They then opened the EHR and oriented themselves to the patients’ previously documented information while their patients either silently sat idle or concurrently related their reasons for the visit.” Some physicians avoided this by first interacting with patients and listening to their concerns before engaging with the EHR, but the disruptive effect of the EHRs were clear. It was almost as if the focus of the encounter switched from the traditional subject (the patient) to the means by which the subject’s information was recorded. Patients with minor medical problems seemed most satisfied with the use of EHRs during their visits, since the EHRs’ preloaded data entry templates enabled attending physicians to “point-and-click to complete the history, physical findings, assessment, and plan.” This benefit did not extend to all manner of visits and patient complaints, however. The authors note that these templates “did not attend to the patients’ narratives or emotional issues, nor did they help manage the complexities of patients with multiple or chronic complaints.” In other words, patients with diseases and conditions that conformed to the technical dictates and limitations of the EHRs had the most positive experiences, since their physicians’ behaviors were altered the least by implementing the EHR workflow. The relationship was necessarily altered by the technology intended to facilitate and improve that relationship.

The Devil is in the Details

One passage in the report in Annals was particularly instructive. It illustrates that whether information technology aids or hinders the patient—physician relationship depends on the dynamic of that relationship. The authors report that physicians displayed “three distinct types of practice styles related to EHR use. Informationally focused physicians commonly positioned themselves at their computer monitors and used computer-guided questioning to focus on problem-oriented details. Physicians with an interpersonal style were led by patient narratives; they either sat or stood away from the computer or faced their patients using the mobility of the computer. Physicians with a managerial style alternated their attention in defined intervals between patients and the computer…Whether physicians perceived the EHR as important in developing the meaning of the encounter influenced how they used it. Those who saw the EHR as a means for collaboration were more likely to share the screen with their patients than those who used it more narrowly as a medical record.”

Are We Making Mountains Out of Molehills?

So, what are physicians to make of all this talk of changing relationships and dynamics? In the case of EHRs, it’s still too early to tell, but studies such as the one reported in Annals of Family Medicine indicate that the matter deserves a great deal of study and consideration in order to avoid negating EHRs’ benefi cial aspects by allowing their introduction to compromise interactions with patients. When it comes to patients’ use of the Internet and their assertiveness in presenting information and expectations that physicians will incorporate it into treatment, MDNG is (and has always been) of the opinion that more is better. Far from representing some sort of threat, patients’ newfound confidence is something to be encouraged as it can lead to a deeper, more dynamic relationship with their physicians. We suspect most of our readers will agree. Besides, you’re still number one in your patients’ eyes. A study in the December 2005 Archives of Internal Medicine indicates physicians are still considered by 62% of patients to be the most trusted and highly valued source of medical information. When asked where they preferred going for specific health information, more than half reported that they wanted to see their physicians first. Of course, when questioned about where they actually went for information, 49% reported going online first, with only 11% seeing their doctor first, but don’t worry; that’s just a reflection of the Internet’s proximity and convenience. We think.

One Final, Rather Sour Question: Will Information Technology Inadvertently Promote Regressive Patient Selection?

Perhaps one of the most insidious ways in which increased adoption of information technology may alter or even compromise the patient—physician relationship in the not-so-distant future is through the externalities some fear will accompany the transition to P4P, a concept that is heavily reliant on health IT. Namely, will P4P financial incentives tied to achieving acceptable treatment outcomes (as determined by adhering to pre-determined guidelines and meetings target outcomes) induce practitioners to (consciously or subconsciously) select only healthier patients and/or those most likely to be able to meet treatment goals? How might this alter patients’ opinions of their physicians? E-mail MDNG editor Chris Cole at ccole@mdng.com to set him straight on this.