Good Ideas and Luddism

From Wikipedia

My recent post on the subject of emails from patients raised more eyebrows than I expected.  It also put me in a position I am unfamiliar with: looking like a luddite.  Perhaps I am not forward-thinking enough in my reluctance to embrace this advance.  Perhaps I have gotten conservative as I grew grey.  Electronic communication is a great idea (I am doing it right now), so why not apply it to my medical practice?  Has Ned Lud gotten into my circle of influence?

This is, of course, extremely ironic.  I lived so much on the cutting edge that my butt developed calluses.  The calluses, however, were not just put there by the edge, they also came from occasional kicking.  The problem is, I have an addiction: I am addicted to change.  I am constantly looking for new and (perhaps) better ways to do things, then impatiently going after anything new and shiny.  This served us well in the sense that I got us on EMR, got it working well, and have continued to keep us away from repeating mistakes too often.  If something doesn\’t work, I am quick to look for the cause, and more importantly, how to fix it.

I had all sorts of good ideas, often many at one time.  But this caused problems.  First, the ideas were sometimes stupid.  Stupid ideas don\’t always look dumb before they are tried.  Often changes had unintended consequences which made things harder instead of easier.  The other problem was that too many changes at once causes change burn-out.  People get tired of change, even if the changes are just little tweaks to the system.  After a while I realized that I was actually the cause of many of the exasperated expressions I saw in the office.  I understood the following: a good idea at the wrong time is a bad idea. This has become a mantra for me in the office which has allowed me to sit on my hands when I felt the urge to change.

A good example of this is the tablet PC.  Microsoft had the idea 10 years ago, coming out with an operating system built around a touch interface.  Did it catch on?  Not really.  Why not?  Not because it didn\’t work – I used these tablets and they did just fine – but because they didn\’t fix an important enough problem.  So are tablet PC\’s a bad idea?  Not anymore; ask apple (and the 20 gazillion apple disciples who stood in lines for iPads).

So what about email consults?  Why not take email from patients when it would suffice as an alternative to coming in to the office?  It would save us hassle (I don\’t want to see people for unnecessary stuff), would potentially make money (some insurance does pay for it), and make patients happy.  Sounds great.  I want to do it.

But a good idea at the wrong time is a bad idea. We are already emailing labs, allowing patients to request appointments and refills electronically, and getting ready to make some of the medical record available 24/7 online for all of our patients.  We are also in the process of complying with \”meaningful use.\”  We are upgrading our system to a newer version.  Our plate is full.

But even more importantly, we need to continue offering care.  We have to keep this plane flying while we rebuild it.  People are getting sick and wanting care while we attempt to change.  Implementing e-visits is a huge task – very disruptive of our current processes.  In the long run this should be a good thing, but one of the main reasons we have been successful in not only adopting EMR, but also being quite profitable as a private primary care office, is that we approach change very cautiously.  The bigger the change, the more planning is required.  We do change; we just take time to make sure we do it well.

That\’s not Luddism, it\’s being careful.

You can get 15% off mens\’ scrubs with code \”mens_value\”

11 thoughts on “Good Ideas and Luddism”

  1. Your logic makes sense to me. And there’s also the risk with email consults that the communication from the patient could be so poor as to lead to a mistake in the recommendations you give. Sometimes all you need is to hear the complaint. Sometimes you really need to see it. Better to err on the side of caution.

  2. My take: Dr. Rob is considering the problems with accepting e-mail from acutely ill, ‘normal’ patients and most of those who responded fall into the chronically ill category.
    Managing chronic conditions takes enough time and energy (and certainly causes enough stress) without adding phone tag to the list. I think e-mail would work anytime it can be initiated by the physician instead of the patient. If you find yourself telling a patient/caregiver, “I’ll call you”, then consider adding, “or e-mail, if you prefer”. I’m sure you will get some grateful takers!

  3. I am happy that your EMR has been an anti-Luddite success. Our group will convert to EMR this month. We are looking forward to this with the enthusiam that one would have facing rotator cuff surgery, or successive root canal procedures. The senior guy in our practice, who doesn’t use e-mail, regrets that he cannot retire and miss the fun entirely. I’m too young to retire and to old to be an EMR groupie. E-mailing patients, which I oppose at present, is inevitable. It will be driven by patient demand, among other forces. Like every other ‘reform’, it will solve some problems and create others. E-mail will seem downright ‘up close and personal’, once telemedicine gains a foothold. Dr. Welby has been replaced by Dr. Blackberry. I am happy for much of the amazing progress I have witnessed, but I am sorry for some of what we have lost.

  4. Best: face to face
    Not as good: on the phone, complete with voice inflections, pauses, follow-up questions

    Nowhere near as good: e-mail, with misinterpretations, lack of inflection, maybe not even written by the person who signs it

  5. “Nowhere near as good: e-mail, with misinterpretations, lack of inflection, maybe not even written by the person who signs it ”
    I’m wondering how this compares to referrals? Or notes between physicians? Would those be handled the best face to face? Over the phone? Should I ask my daughter’s specialist(s) to update her pediatrician in person from now on?

    I’m not being sarcastic. Communication among my daughter’s specialists is a nightmare.

  6. I really don’t think patients expect e-mail to replace how you are diagnosed with an illness by a physician. We all pay attention when you take our blood pressure and listen to our heart and lungs.
    I can see a practice having an e-mail or ‘chat’ feature in place of a nurseline. Our pediatric nurseline is a really nice support system for nervous parents, most often giving you the nudge ‘you are not making it too big a deal, bring her in’. Even e-mail to get on their call back queue as opposed to being on hold forever would be great!

    My interest in this issue is preceding the upcoming month of September, in which my daughter has a record breaking number of appointments with FIVE different specialties. Two probably aren’t even necessary, but I do as I am told (usually). I won’t have anything in writing from any of them. Sometimes one will ask what the other said, then act like they don’t believe me when I tell them. In July, one told me he would call me, our pediatrician, and another specialist. He hasn’t called me yet, so…….

    (Please, when you read ‘five specialties’, do not imagine my child as a train wreck! At a large family gathering yesterday, extended family had no idea she has any illness at all as she ran around with all the cousins. Despite the frustration, we and her doctors must being doing something right.)

  7. I disagree with luddite md. I think there are some really good sides to email – especially the asynchronous nature of the communication. It is why I am blogging and not holding talk radio. You can structure questions on your website to make sure you get the information you need. The other nice thing is that people have to log on to ask questions – that means that only people who are authorized to access the person’s record are able to ask questions. The risk is much lower than you think.

  8. I’ve griped about this in the past. Docs are technophobes in general, so I can’t send info to specialists even if I want to. But as far as face to face communication? Again, you run into the problem of stopping what you do to talk when someone calls you. It does happen, but only the minority of time. The patient ends up being the conduit (or parent, in your case). It’s frustrating and sad, but it is reality.

  9. Hmmm… I had a counselor once who would take emails, but only for scheduling or “hey, remember to talk about this next week” things – she never actually offered advice over email. And thank goodness! One of the great things about having a relationship with your health care provider is the… intimacy? Granted, a therapy situation like I’m describing is quite different from, say, needing a refill or finding out test results.
    But – As someone who goes to a doctor fairly regularly, I go out of my way to find a physician whom I trust and respect, and who I know will hear me out and believe me. And when I’ve found that doctor, then I – not enjoy, but… appreciate? find healing in? – the face-to-face visits. I had a resident physician as my PCP when I was in college, and even if she couldn’t offer me any better migraine prophylactics or whatever, the fact of sitting in a room with someone who cares was healing. AND the fact that she took an extra 30 seconds to talk about life stuff that wasn’t relevant (I was applying to medical school at the time, and she had gone to my college before medical school, so we talked about the school, or the applications, or whatever) made me more likely to trust her the next time I came. I see a neurologist at the headache clinic at Dartmouth now, and when I see him we talk about our shared experiences of going to school in the Bay Area – not medically relevant, but it creates that trusting relationship. And, though I don’t enjoy going to the doctor, I do like him, and like being heard, and like the banter. Maybe I’m just old-school, but as a patient / med school drop-out / someday-CNM, I think the healing is in the meeting of 2 people, something that would be lost in an e-visit world. I read an article recently (New York Times?) about a study showing that conducting the physical exam doesn’t actually give doctors much information, that the exam is out-dated. I was horrified because I can’t imagine (or, rather, don’t want to imagine) a world in which doctors don’t touch patients. I had a patient in medical school who told me his doctor wouldn’t touch him and that he thought that the (male) doctor must be afraid of him because he (the patient) was gay. Maybe the doctor didn’t need to touch him much to diagnose and treat, but, for that patient, the lack of touch meant that he was untouchable.

  10. Interesting! In the medical profession, any change comes with its own risk since it involves human lives. People are skeptical of changes when it comes to healthcare. Nevertheless, changes are necessary for any realm of human life. Author has effortlessly put down his observation and dilemma succinctly.

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