Dr. Wes (a cardiology blogger who all should read) wrote a very compelling post about technology and the bondage it can create for doctors.:

The devaluation of doctors' time continues unabated.

As we move into our new era of health care delivery with millions more needing physician time (and other health care provider's time, for that matter) - we're seeing a powerful force emerge - a subtle marketing of limitless physician availability facilitated by the advance of the electronic medical record, social media, and smart phones.

Doctors, you see, must be always present, always available, always giving

This sounds like dire words, but the degree to which it has resonated around the web among doctors is telling.  He continues:

Increasingly the question becomes - if we choose future doctors on their willingness to sacrifice for others without expectation of appropriate boundaries and compensation - will we be drawing from the same pool of people as the ones who will make the best technically-skilled clinicians? What type of person will enter medicine if they know that their personal life will always take second place to patient care?

Dr. Brian V (long last name, but another one who you all should read) adds his voice to this:

It started with the pager and it’s evolved to real-time social media.

I’ve seen it too many times:  Physicians excited to please open the door to unlimited patient email only to see themselves shutting their families out at night as they answer questions – all for free.  And those physicians who suggest that emails should carry a fee are indicted for greed.

We have been on EMR for 14 years, yet we don't accept email from our patients.  We could do it, but we don't - and both of these doctors hit on the head the reason why we don't.  The goal of IT in our office can be summed up in one word: efficiency. The practice of medicine has become dominated with non-clinical tasks.

  • We have to gather information and organize it.
  • We have to serve as an "information central" for our patients, collecting from disparate sources to make informed choices.
  • We have to comply with the maze of government and insurance industry rules.
  • We have to give information to patients and to other medical providers.

So what actually happens in our office is less medicine and more information management.  IT allows us to do this in less time, leaving more time for our patients.

Accepting emails from patients at this point would mean more time spent doing unreimbursed tasks.  Actually, it would potentially decrease our revenue, handling problems outside of the office (for free) instead of being paid for our services.  Doing so would give us three options:

  1. Working extra hours to make up for lost revenue.
  2. Giving free care via email and just accepting less pay, seeing less patients total.
  3. Spending less time with each patient to make up for the decreased revenue.

I am busy enough that I don't want anyone to have to come in for things I could handle remotely.  Email communication with patients sounds ideal in many ways.  But unfortunately, the business case for this is so bad that we can't open ourselves up to patient emails.  One answer would be to have a minimal charge for an e-visit ($20?), which would be credited toward an office visit if the e-visit warranted that the person come in to be seen.  The amount needs to be enough to ward off frivolous questions, and would have to be applicable to ALL insurances (including Medicare and Medicaid).

Email also works well with the idea of the "medical home," which reimburses doctors for overall care of populations.  (I give my opinion on the medical home in this post.)

Until this happens - until we are somehow paid for giving care outside of the office - this useful technology will remain unused.  Is it greedy to not want to give things away for free?  Is it greedy for me to not want to spend less time with my family, make less money, or spend less time with patients?  Is it greedy to think I am worth $20?

If so, you can call me greedy.

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