In May’s “Rheuminations” column, “To Document or to Doctor?” (p.6), Dr. Pisetsky speculated on whether paperwork burdens are detracting from patient care. Several readers wrote in with their views on the “document-or-doctor” dilemma. We’ve published a selection of those responses here, and we want to thank everyone who wrote in. Keep those letters coming!—The Rheumatologist’s Editors
I just finished reading your editorial in The Rheumatologist on the nuisances of documentation in modern medicine. I feel very strongly about all that you wrote in the article. As a junior clinical rheumatologist in an academic setting, I almost always feel torn apart by the standards in patient care that I believe in and the pressing factor of productivity, which is inevitable in today’s healthcare economy. Documentation plays a major factor in this equation, as you nicely displayed.
Ironically, the time I spent in reading your article and dropping these lines resulted in a backlog of three charts due for “comprehensive” dictations which will probably be put off as my next patient starts calling for the nurse or looking at his watch. It looks like my wife will give me the same look again while reheating dinner tonight!
Thanks again. Always a pleasure to read your thoughts.
Firas Alkassab, MD
Assistant Professor of Medicine
Division of Rheumatology
University of Massachusetts Medical School, Worcester
I enjoyed reading your piece. I agree 100% with you. However, short of radical changes in our medico-legal practice climate and ways that Medicare looks at physicians and healthcare providers, I am afraid we will continue to treat the chart and computer a lot more than we treat our patients. In my opinion, the first step to fix what corrupts our current healthcare system is reforming the climate in which we practice, followed by vast improvements in the reimbursement mechanisms. To begin with, the current CPT codes and levels of service don’t make a lot of sense from a clinical standpoint. For example, the diagnostic code for rheumatoid arthritis is just one number, and it does not specify how bad or advanced the disease is, or how involved or uneducated the patient may be about his or her own disease. There are no code modifiers for the litigious patient that clearly demands more extensive and time-consuming documentation.
The patient–doctor relationship needs to be freed from interference by others with a vested economic interest in our professional interaction. If there is a factor that will improve the quality of the medical care we provide, it won’t be more CME courses or recertification exams but rather limiting the number of patients we see in the clinic or in the hospital. It is hard to imagine providing good quality care seeing patients every 10 to15 minutes, working at a frantic pace, and having to document like crazy in case Perry Mason comes around later. To a certain extent, we in academia are privileged to have the luxury of seeing patients at perhaps a bit more “relaxed” pace, working with fellows and residents and “double-checking” diagnostic impressions and therapeutic interventions.
Emilio González, MD,
Professor of Rheumatology
University of Texas Medical Branch,
For 40 years I practiced rheumatology as a solo practitioner. During those years, I followed your contributions religiously and appreciated your being “one of us.” In 2005 I closed my practice and joined the Clinical Documentation Improvement Program at St. Francis Hospital in Roslyn, N.Y. As you might expect, I had an inclination to comment on your article, “To Document or to Doctor?” For the last three years I have been part of a team that tries to encourage doctors at the hospital to document what they do to provide excellent medical care and part of the unit that regularly reviews the published Medicare documentation requirements in the Federal Registry. The latter rules and regulations are not an option. Contrary to general opinions, they are prerequisites not only for accurate billing (reimbursement) and accurate statistics and databases, but also are clearly designed to improve medical care by insisting on accurate diagnosis (when possible), matching treatment to diagnosis, and—importantly—improving communication between those numerous professionals involved in patient care. Given my last three years of experience with clinical documentation, I have several comments on your article.
Having been trained at major institutions from medical school (1952–1956) to 1964 when I went into practice—history, physical, review of symptoms, review of record, and complex decision-making—I think that these represent what goes into good medical care and only secondarily, in this era, reimbursement. If adding the words acute, chronic, systolic, and/or diastolic to the diagnosis congestive heart failure takes away from the care of the patient, one has to doubt the patient’s care. So, too, if adding acute blood loss anemia to the diagnosis of anemia, and if acknowledging a nurse’s note that the patient has a decubitus ulcer means that the doctor may actually have to turn the patient over in bed, then medical care is actually in doubt.
I could go on and on about accurate documentation and the quality of medical care, the accuracy of databases (number of line infections, pressure ulcers, and Foley catheter infections), and the inability of one doctor to follow what has happened to the patient from progress notes without adequate documentation.
I intended this comment only as perspective from the other side and to possibly refute the idea of documenting or doctoring.
Howard Weiss, MD
Clinical Documentation Improvement Program
St. Francis Hospital, Roslyn, N.Y.