I was certainly in accord with your recent article in The Rheumatologist (“To Document or to Doctor?” May 2008, p. 6). I am reminded of the philosopher Descartes who said, “I think, therefore, I am.” Nowadays he would be changed to, “I document, therefore, I am.” The need for the extent of documentation required particularly through Medicare seems more to provide a means of tracking the doctor. It is as if to say, “I was there.” We all are seeing the massive amount of documentation hiding the essence of what we really want to know about the patient.
I remember in a previous article, perhaps in the Annals of Internal Medicine, the observation that with electronic medical records physicians have found a way to rapidly document, and still see and take care of patients. They felt the next requirement would be the amount of time the physician actually spends with the patient. Obviously, if the goals is quality of care then most of this is bogus. If, on the other hand, the goal of these requirements is to decrease the amount of care that you can provide and decrease the number of patients you can take care of, it would make more sense.
Perhaps in the future the government will reward through its Medicare system the physician who knows the least about the patient. The more time he spends, the greater his reward. Those who have knowledge and information and can see a patient more efficiently would essentially be penalized. Do you suppose that eventually they will pay more for the slowest surgeon?
In doing some business studies previously, I found a lesson to be learned when the government is entrusted to decide where emphasis needs to be placed. Apparently, in Russia the government decided that a measure of the value in a Russian truck was based on its weight. Very soon the manufacturers responded and in short order they had the heaviest, most inefficient trucks in the world.
If we allow the government to take the next step and limit the patients we can see according to the time spent then we will see ignorance and inefficiency rewarded—poor prospects for our patients in the future.
As you know, the shortage of rheumatologists will likely only become an increasing problem. It would seem, again, if the interest was patient care rather than limiting the amount of money being spent, that rules such as having the physician on the premises when lab is done or injections are carried out would not exist. With the current technology, within 24 hours we could make decisions regarding lab results and contacts, perhaps through physician extenders in outlying clinics, and provide rheumatology support to our more rural physicians. We would still, of course, be responsible for the lab results and therapeutic decisions made, whether we were on the premises or not.
I remember in my training as a medical student, one day as I obsessively wrote down and documented (to a degree that would probably be required today), a wise resident pulled me aside and asked, “What is the name of this section in the chart?”
“It is the progress note section,” I responded.
“Well, do not put anything in there unless there is progress,” the resident said.
I suspect if Dr. Stead were alive today he might modify his famous saying to, “What this patient needs is a doctor—not a document.”
Jeffrey W. Wilson, MD, MBA
Lynchburg Rheumatology Clinic,
Lynchburg, Va.
