I was talking to a fellow physician about a mutual patient. I had information that would help him in their care and he was taking the unusual step of asking me for my information. I was impressed. "Could you fax me those documents?" he asked. "Here's my fax number."
I scrambled to get a pen to write down his number. Then I had a thought: "I could email you those documents much easier. Do you have an email address?"
After a long pause, he hesitantly responded, "I would rather you just fax it." He said no more.
This is a typical reaction I get from my colleagues when suggest using the new-fangled communication tool called email. The palms sweat, the speech stumbles, and the awkwardness is thick in the air. It's as if I am suggesting they join me in an evil conspiracy, or as if I am asking them to join my technology nerd cult. There is a culture of fear in our healthcare system; it's a wall against change, a current of stubbornness, a root of suspicion that looks at anything from the outside as a danger. Instead of embracing technology, doctors see it as a tool in the hands of others intent on controlling them. They see it as a collar on their neck that they only wear because others are stronger than them.
It's the only reason I can see for the resistance of a transforming technology. It's the only way to explain how they would favor a non-system that hurts their patients over a system that can improve their care immensely. After all, what good is it to embrace a technology - no matter how good - if it will take away their ability to practice medicine? "It's good for you!" they hear from politicians and academics, but they see it as a poison pill.
What gives me cause to use such strong words? Surely it's not that bad! It is, and what makes me so sure of it is the very high cost of their resistance. The cost of this fear is huge, and so the fear itself must be bigger for a healer to accept that cost. What is the cost?
We see our patients without information. The call from the specialist I described at the start of this post was a truly rare event. Most of my consultants don't expect to get information from me, and I expect to work without their input. All of this has happened despite my repeated attempts to improve our system.
- I have offered to send our referrals with attached appropriate documents. I can do this very efficiently using email.
- I have tried to send labs, x-rays, and other information to specialists when I felt they couldn't do their job well without them.
- I have requested that they stop mailing their information to me, instead faxing them to our server.
- I have offered our hospitalist physicians after-hours access to our records for our patients.
Ironically, the only physician who has embraced my offer is an ENT at our local teaching hospital who specializes in parathyroid surgery. I shoot him an informal email when I have a suspect calcium level and within the day I get a response. In exchange, he gets consults with a full set of labs and can practice with greater efficiency. He also sends me quick notes on my patients when he sees them, asking me questions to fill any gaps.
The total lack of communication results in huge cost to our system. It's not that the communication tools are not there, it's that they just are not used anywhere near where they should. Examples?
- A woman came to my office recently after being hospitalized. I never was notified of her hospitalization, only finding out when she came for a "hospital follow-up" visit. While in the hospital, she was found to be anemic and so had a workup for this condition. This workup included a full consult by a hematologist and a gastroenterologist. If my records had been looked at, they would have noticed that I did a workup 6 months earlier for her anemia.
- Specialists not accepting email copies of the labs I run usually end up repeating the tests. For specialists like rheumatology - where the diagnosis is largely made on the basis of those labs - this elevates the cost by several thousands of dollars.
- I have had patients rebuffed by consultants who "didn't know why I sent them." Nobody calls, and nobody accepts email. I could send them whatever information they need in a matter of minutes if they would accept email. Heck, they could even text me if they wanted.
The real cost, of course, is to the patient. The Hippocratic oath says we should "first do no harm" as physicians. Yet our non-system of communication does just that, and even kills people.
So why would presumably smart people reject a technology that could improve care, reduce cost, and reduce frustration? Did any of them order gifts from Amazon? Do any of them bank online? I am sure they do, and they do so because it makes things easier and more convenient. So why does that ease and convenience not apply in medicine, which is far more broken than shopping or banking ever was? It's not fear of technology.
To be honest, I don't really know. My best guess is that it is the overwhelming sense of pessimism most doctors feel about their profession. Docs are second-guessed by lawyers, patients, TV shows, insurance companies, and the government. The fate of medicine is not in the hands of doctors, it is in the hands of politicians, corporate executives, and malpractice attorneys. It seems to me that the only way to avoid more scrutiny and to hang on to some control is to hold tightly to what we've got: our information. Once that information is on computers it is far more accessible by others, and this is a bad thing if the goal is to retain full control.
So are docs just power hungry, wanting total control because of their inflated egos? Some are, but most are not. Even the most technologically-minded of us, however, have an increasing unease about the intrusion of others on our ability to do our job. I don't want to be thinking about attorneys when I am prescribing medications. I don't want to withhold information important from the chart because I know patients will be reading it. I don't want to be forced to include a lengthy justification of a procedure in my notes to make the insurance company happy. As it stands, it sometimes feels like anything we include in our records "can and will be used against us."
If someone like me, a physician who embraces technology, feels increasingly penned in by the increasing number of people peering at what I do, it is very understandable that other physicians reject technology outright. They'll quit before they give up their independence.
Is it stupid? In some ways it is. It certainly is a rejection of the centrality of what's good for the patient. But our system can't afford to alienate physicians at this time. If technology is going to be pushed, there needs to be a reassurance that this won't be used against them. I am frustrated at the lack of acceptance of technology, but even more frustrated at a system that is hostile that forces docs into this foxhole.