The Cost of Fear

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?\”

Silence.

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?

Frustration

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.

Cost

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.

16 thoughts on “The Cost of Fear”

  1. Oh, please! It has nothing to do with fear. I also use email to communicate with patients (those few who seem to want to), because it works. I don't use an EMR, not because I'm afraid of it, but because it would neither imporve the quality of care that I give, make it easier to deliver that care, or produce more revenue from giving that care.

    Your consultant probably would have had to print out that email (not all laptops are permanently connected to printers) and have a staffer input it into his EMR. Maybe he receives faxes through his computer, and therefore faxing would be the easiest way for him to get the info into the EMR. Or, if he were using paper charts, your fax could go directly into the chart, whereas he'd still have to print out your email.

    The real problem is the lack of interoperability between different EMR systems (not all of which include internet components like email). Just because you've managed to use (and afford) a high-tech office system of EMR/email/etc. doesn't mean the rest of us are stupid or fearful of technology. Respectfully, this kind of post is counterproductive to the ideal of working together to get the bloated HIT folks the hell off our backs and create a single system that works for everyone.

  2. Dino, I agree with you in the EMR realm (although we have made much more $$ because of our EMR), but I am not taking about that. I am talking about use of communication tech. The upside is so big to use and little relative downside to the email communication. The ENT I communicate with is giddy about it and tells everyone how great our system is, yet all other docs treat it like Ebola virus. It is fear; there is no better reason I can think of. Email does not cost them money. Printing our emails is no more costly than fax and we can send far more/better info.

  3. I completely agree. I am so happy that the two referral hospitals I work with most often send me referral letters via email, and accept email from me as well. I think veterinary medicine is a little bit ahead of human med in this regard, just based on informal chats with my health care colleagues on both sides of the divide. Still, plenty of docs don't use email and it's crazymaking.

  4. Does it have anything to do with HIPAA compliance? Perhaps they don't have the requisite security measures to be HIPAA compliant available for their e-mail.

  5. If it is HIPAA, it is not because of our email. Ours is 100% compliant – we use it to email results to our patients. No matter how much we reassure and talk up the convenience, they avoid at all costs (so it seems to me).

  6. So many good points about wasted time and energy! I am a Chronic Disease Nurse Case Manager and I encounter the same exact thing. It would make our jobs so much easier, but more importantly, help the patients, if information was exchanged efficiently and quickly. But so many people, clinical and administrative, are resistant.

    Some people are just jerks and won't work with you, some people are 'too busy' or afraid to try to learn something new. Some physicians are so exhausted when they get home I had this discussion with my PCP) they are just not computer people.

    While I don't know what the answer is, I do know that they will have to get on board eventually, because it is the right thing to do for optimal patient care.

  7. I have had similiar experiences when trying to obtain a patient's old records. I wonder if HIPPA plays a role as well. Seems like that everyone claims sharing of information falls against HIPPA regulations.

  8. While I agree email, etc. is a great way of communicating, my first knee-jerk reaction would be 'Arrggghhh! Patient Confidentiality!'. Email, for example, has a reputation of being insecure, and while I know there are ways of ensuring this, I'd bet reasonable money that many people don't. Not a fear of the technology itself, but of how it can go wrong?

  9. Yes, but most of the folks who would do this still do online banking and shopping without problem. It needs more confidentiality than that, but that does not justify the stark terror among doctors.

  10. A very interesting post. From the patient's perspective, I wish all medical providers were so tech-savvy. I live in a very backwater town in Tennessee. Yet, my GP is connected to everyone inside and outside of his practice group such that, when he sends me for a consult, the new doctor already knows why I am there, what my background is and what tests I have already had. This is very refreshing. On rare occasions, I end up with a doctor who is not so connected. That is when the initial visit is not so much a work-up as it is the re-invention of the (medical) wheel.

    My pet peeve about charting, however, is that I bring to any appointment a complete list of my meds by name, dosage and frequency. I then watch the nurse laboriously recopy all of that information, sometimes reducing the name to it's OTC equivalent (Advil instead of the listed Acetaminophin) and sometimes transposing information. Don't they have a decent two hole punch?

  11. Alternative explanation: the other doctor may be fearful of the security of the message. I once worked at a Fortune 100 company where we all received emails forbidding us from communicating with our outside attorneys without ENCODING our messages. Now, they didn't provide us the software to do it! With all the concerns about internet security I can imagine a doctor feeling better about faxes. HOWEVER, it's also possible he or she doesn' t know how to use email.

  12. Dr. Rob, I am a 58 yr old person. I was told one time you can not teach and old dog new tricks. That is far from the truth. I have found that in a lot of fields, people are afraid of our new technology. My father once told me, You are never to old to learn. I found that in my life, that has been a blessing. It has given me promotions and more money to live in our wonderful country. I agree with you, people need to use and save us money. Keep trying. This old dog is still learning.

  13. As a patient, I would like to see electronic records used more frequently. No-I don' t necessarily want to see all the medical jargon that I don't understand & try to wade thru it, but I very much appreciate the way my PCP sends the results of any tests he does thru secure email with understandable notes on the meanings. It's nice to be able to print off these results & take them with me to other drs who might be need to see them or want to order the same tests if they had not already been done. I would also like the option of being able to see reasonable parts of my medical records online so if I ever move or needed to access them for any reason, I could–but i also understand a doctor's concern about putting it out there for patients to read. Also-what are the dangers of it being used against us by say a company who wanted to hire us “checking on our medical records” as they would a background check? Would the medical records be secure enough to resist that kind of intrusion? As you say-anything online can & will be used against us. In certain cases, this could include the patient as well as the doctor.

  14. As I've stated here before , we trust technology to do all of our banking, investments, home loans, taxes,…I could go on and on.

    I'm sorry, but I just don't get the issue with Patient Confidentiality – I'd much rather risk the world knowing that I had high cholesterol than knowing my financial information and we go through each day emailing that info with a fairly high level of confidence.

    The medical community needs to get up to speed with the rest of us.

  15. As I've stated here before , we trust technology to do all of our banking, investments, home loans, taxes,…I could go on and on.

    I'm sorry, but I just don't get the issue with Patient Confidentiality – I'd much rather risk the world knowing that I had high cholesterol than knowing my financial information and we go through each day emailing that info with a fairly high level of confidence.

    The medical community needs to get up to speed with the rest of us.

  16. It's not just the docs that are reluctant. I used to work as a discharge planner, and would e-mail local ECF's and L-TAC's admitting coordinators regarding bed status, and that I have someone with such and such insurance, needs, expected outcome, etc. Since all of us had our e-mail on all the time, I would get a response in 30 seconds. My co-workers would laboriously write out a request, fax it, then call to say they faxed a request, then wait for the faxed return and phone call. Surprisingly, I was frequently done for the day and home by the time they got all that together. Administration tried to stop me on the “confidentiality” clause, but I just reverted to initials, age and sex of the patient.

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