With the demand of the conversion to an EMR, the staff is
expressing concern that they do not have enough administration time to properly
document the patient’s experience. They
feel that perhaps the service to our patients is declining because the amount
of time they have to spend on the phone with them has also declined. They feel that the high standard of service
that we have had for many years is starting to be affected by the lack of time,
that they need to work with this program and also spend the time with the
patients both in person and on the phone.
This is a concept that was written about by Dr. Swenson in a book he wrote about 10 years ago called “Margin.” In it he describes ‘margin’ as the time in our lives when we have nothing to do. It is during this time that we spend on relationships with other people, with ourselves, and with God. Life used to afford a lot of margin time in our day to day activities. People will get go to work at 9 o’clock and get done at 5, come home spend time with their family or at home or in the evening reading a book or just writing letters to friends and family. But society has speeded up the demands of the work and all the things that should be done. This starts to eat away at the ‘margin’ little by little until the point where person has no ‘margin’ at all. This creates an incredible stress and tension on the body and the mind. Dr. Swenson is a family doctor, who saw this in his patients as they come in with all of these ailments that are stress driven.
I see this same scenario playing out in my practice right now. As the ‘margin time’ (administration time to spend with patient care) has disappeared, because of the demands of the EMR system, the time my staff has to work with the relationships with the patient has created a tension that is difficult to describe. In this context, it takes away the joy of practicing medicine for my staff and for myself. Yes, I say for my staff. My staff practices medicine as well, as they interact with the patient, listening to their concerns and offering solutions and options for treatment based on the treatment plan. This time spent with the patient has been diminished because of the demands of EMR.
The question is what are we going to do about it! There are a couple of options we are to currently exploring and this would be the subject of a future blog. Basically, in a nutshell, the options include adding more staff or decreasing the time with the patient, which should decrease the profit of the practice. That is my burden.
I have written many times before about profit-based medicine. This is the underlying driving force behind most corporate-type dentistry. The goal of a corporation is to generate profits for those shareholders. It works very well in a capitalistic society, but it does not work very well for medicine. I have an example that I have used through the years to illustrate this fact.
Let us say, you start to have headaches. At first, they are tension headaches, but then it gets to be more like migraines. Let us say, you start to have headaches every single day, so you decide that you need to have this checked out by a doctor to see what is going on. You make an appointment to see the doctor and you get in to his office. The doctor walks in and your diagnosis is going to be headache. What you do not know is that when the doctor uses a diagnosis of “headache” then he will get paid for a 10-minute consultation by the corporation because that is what the insurance company will pay. The insurance code for “headache” generates a payment for 10-minute consultation. Therefore, if the doctor needs to spend any more than 10 minutes with you to figure out the type of headache you have, then he will basically be doing it for free or at a loss. A good doctor of course would always spend the time he needs to understand your headache and properly diagnose the type of headache and give you a proper treatment, however, as time goes on, there are some doctors who will not be willing to practice at a financial loss and will start to delegate more and more towards his staff so that he will only end up spending 10 minutes with you.
I have seen in my practice 100s upon 100s of patients who have fallen through this particular crack in the medical profit driven model. Ten to fifteen years ago, this is something that occurred once a month or so, but in the last five years or so this has become more common not just with headache, but other types of facial pain conditions as well. The patient spends over 2 hours in my office and 30 minutes with me in order to figure out what is the cause of their headaches and facial pain. It just takes that long because it is often very complex and has many different causes, but as National Healthcare becomes a norm, this will be based on profits and loses and finances instead of what is best for the patient. I am fearful that I will be seeing people on a daily basis who have been failed by this type of system. I am resolved never to get into this type of medicine so that I can help these patients who need the extra time and care.
It is sad to see this type of system evolve in medicine and now in dentistry. I hope that it does not last long and that people will demand better care and a more traditional approach of a doctor-patient relationship. In other words, these complicated patients need to demand that the proper amount of time to diagnose the conditions is given to them.
These are certainly times of change, as is experienced in every generation. The last few generations' tradition has always been the highest priority of change as people build on tradition to make things better for life in general. That was true of my generation as well, but now in the last 10 years as I am nearing the end of my work life, things have changed dramatically to the point where “traditional” is no longer a priority. In fact, tradition has almost become the antithesis of the progressive movement. What does that mean to health care and the way it is delivered to patients?
In Dentistry, I see the trend away from private practice and the one-to-one doctor-patient relationship into a corporate model where medicine is a commodity that requires a profit. Medicine started on that road 25 to 30 years ago and now Dentistry is fast on its heels. As dentists in my generation come close to retirement, the traditional model was that they would find some young dentist to buy their practice and take over the care of the patients. However, what is happening is that as dentists start to retire there are no young dentists who want to get into private practice by taking on a huge debt since school has already put them in debt by more than $125,000. Banks are no longer willing to loan the money to buy a practice and the traditional model of transition of practice from one generation to the next is now being changed dramatically.
Large corporations are buying practices and they are changing the structure of the practice to be based on profits. They are bringing in whatever dentist they want, at the salary that they need to make the profits. People and society are looking for change and better ways of doing things. This progressive way of making healthcare a commodity seems to be a way to make healthcare more accessible to more people. The thinking is that it would make it cheaper and therefore more people would have access to the healthcare and dentistry that they need; but in reality, just the opposite is happening. In reality, since profit is the major driving factor in the practice of dentistry, that people are getting unnecessary dentistry done at a fast and economical delivery system. Comprehensive dentistry is no longer profitable because of the time it takes. Therefore, people are going to be getting the type of dentistry that is minimal and economical.
This will have drastic impact on the dental health for this next generation and I am hopeful that society will sooner, rather than later, figure this out so we can go back to the traditional way of delivering healthcare where the patient care is a priority, and not based on profits. Time will tell, and I am hopeful that because patients appreciate a better standard of care, that the pendulum will swing back again to traditional medicine in the future.
I once had an employee of mine ask what the purpose of work was. Ever since then, I tried to get all of my employees involved with this concept because it is a basic human need to have purpose. Work has so much more meaning when there is a purpose to it as well. There are many philosophies as to the purpose of work and the most common philosophy is that it is basically a means of obtaining the things that we want to buy. It is a means of which we get financial ability to exist without having to do work when we retire. For many people that is a good purpose of work and this is what drives them to wake up in the morning, turn off the alarm, get ready for work, and drudge through the day. The most common bumper sticker underscores this philosophy as it says “I owe I owe, it’s off to work I go.”
I believe there is a greater purpose to work. In order to have this other philosophy, one has to have a belief that there is a creator God who created us. If one believes that we are just an evolutionary cog in the scheme of life, then this philosophy would not work. But if one believes that there is a Creator who created man, then this philosophy works very well. I believe that our creator God created us to rule over His creation as His representative. In other words, our Creator created this world and all the animals in it, all the plants, and all the fish and everything we see around us. He is not a physical being living here with us so He created us to represent Him and to rule over His creation. If that belief is a core belief of a person, then work becomes part of this belief system.
The purpose of work, based on the belief that God created us to rule over creation becomes much more meaningful. In other words, the God of history and the God of future is working through the history of mankind for a particular goal or purpose. So when we do our work here on earth, we are working with God and for God to obtain his purpose in the world. In other words, God is working with our lives and other people on a day-to-day basis all through history. At this time, in history, we are here working and helping other people so that God can accomplish His purposes with them. Our benefit comes when we see these people being helped and have a better life. In the healthcare world, from which I live, this becomes a deeper purpose for what I do. The same goes for all my employees. When we intersect with the lives that come into our office and help them get out of pain or help them manage their pain or medical disorders, then we are working with God to accomplish what He wants in their lives.
Helping people then becomes not only the purpose of our work, but the purpose of our existence. This is extremely meaningful and gives a deeper satisfaction into knowing that we are working with our Creator to accomplish a better world to live in, which would have more purpose than just to gain more money in order to make it through the month.
This purpose of work goes into every possible job. The shoemaker makes shoes or repair shoes so that people can walk more comfortable so that they can also do what God wants them to do in their lives. This gives purpose and meaning to work. To work alongside God and what He is doing in this world; ruling over creation and helping God’s creation to get to a better place is the purpose of work.
I have noticed in the last 20 years the effect of commercials on prescription medications. When they first came onto the scene, I thought to myself “what a waste of money.” The reason why I thought that, was because in my mind the only source of prescriptions was based on the judgment, care, and skill of the physician. I had no thought as to how the patient could possibly influence that process. Thus, commercials for prescriptions would be a total waste of money.
However, these commercials have lasted for more than 20 years and I have come to understand other things that I did not know before. In the last 15 years I have had the opportunity to have pharmaceutical representatives come to my office to show me the new drugs that are on the scene to help treat various orofacial pain and other headache disorders such as migraine. I value these representatives because they show me how the drugs work and they are very helpful in helping me to work through various side effects that come along.
Since I spend time with these pharmaceutical representatives, I have come to learn that most physicians do not ask them questions and most physicians hardly ever talk to these people. These representatives are full of information direct from the manufacturer and I find this information very valuable in my patient care. However, physicians do not really seem to have the same value, which caused me to reflect on the commercials that I see on TV.
I know physicians are very busy because of the nature of the healthcare system we have today. They have to prioritize their practice and their care for patients, so I am the last person to question that whole process. However, it seems curious to me as to the efficacy of commercials for prescription medications and its continued presence. Based on what I know and what the pharmaceutical representatives have told me, I think that perhaps that the physicians are open to suggestions by the patients or perhaps the physicians watch the commercials as well and that might be a way for the information of the medications to get into the hands of the physicians.
I just hope that the trend of pharmaceutical commercials is not a bad reflection as to what is happening in healthcare today. I hope it is just another avenue of being able to get information into the hands of doctors. I cannot imagine that a physician could possibly take the suggestion of what medication to use from the patient. That is inconceivable to me.
I have just returned from a facial pain update and have some thoughts as to the future of pain control. As I mentioned in one of my other blogs, there has been no new pain medication in the last 12 years. They have all been rearrangements of current medications and different dispersal systems. What I have learned at this update is that as our understanding of the source of pain becomes more clear, the ability to reduce the pain will also become more specific.
As we understand not just what nerve fibers and neurotransmitters are involved in regulation of pain, but the deeper more specific aspects of pain control is understood at the level of the gene. We are becoming more knowledgeable as to how the body controls its own pain as different genes express themselves at different times with different types of insults. The more we understand how pain is produced at the sub molecular level, the more we understand how we can possibly stop the pain.
Let me try to illustrate what I am talking about. Let's say you live in a community on a beach. One day a ship comes to the area of your beach and every morning at 3:00 a.m., it lets out a screeching noise that goes on for an hour. The ship is too far to shoot at with guns, is too far to throw rocks at it, is too far to scream at it, therefore the only choice we have is to somehow insulate yourself from the noise by putting earphones on or buying a house that is sound proof. That is sort of a way painkillers are today. We do not stop the pain, all we try to do is to mask it or try to reduce the way it feels to us. But wonder if we could build a certain type of boat that will go across the water and in that boat, we could put a bomb or possibly a secret agent to be able to get over to the ship and the ship would greet it as another ship and then the bomb could be let off at the appropriate time or the agent can dismantle the screaming siren. That would be a very specific way to eliminate the pain as we find the “boat” or what they call, “the carrier” to take specific medications to eliminate the pain. That is where the future is. They are also using this in cancer research and in treatment of cancer. The more specific our medications can be, the less side effects there will be and the more comfortable and more effective will be the pain control.
This is a very satisfying profession (orofacial pain) IF it is in your heart to serve people in pain. I always assert that one has to have the 3 Cs to do this to treat people well. The 3 Cs are competence, character, and compassion. I have blogged about these before. One has to be extremely competent and that is based on knowledge of pain conditions. One has to be a person of character because the character will constantly be challenged when treating people in pain, as there is always a shortcut in things that one can skip over to accomplish goals. Goal settings for the patients in pain have to be realistic and those goals are oftentimes set by the treating doctor, as it relates to their character. Compassion is essential in order to adequetly sort out the pain sources because every treatment that one attempts to do on these patients does not always work. The treatment plan is constantly being challenged by responses to the patient and without compassion, these soureces of pain decreases the patients drive to keep coming and the patient goes away without any resolution of the problems. If they know we are compassionate they will keep returning until we have discovered all the pain sources.
One finds that dentistry as a “doing sport” and orofacial pain as a “thinking sport.” In dentistry, one is always doing things to fix teeth and repair occlusion and address deteriorating tissue that is usually driven by disease processes. However, orofacial pain, being a degernative process, is being presented with an intellectual challenge that has to be thought through and figured out before treatment is commenced.
It was not only my drive to help people in pain that got me into this profession, but also this profession appealed to my intellect. Intellectual challenges that complex pain presents with are fascinating to say the least. What satisfies is the desire to help these patients. As you can see, it is a different mindset than approaching people with dental problems. Yes, this type of practice can be done in the context of a general practice, but the passion for this grows, as the knowledge in the patient’s response increases. As one starts addressing the deep need to be out of pain and as the patient’s response to this treatment, it becomes what drives you to treat the next patient. Pretty soon as time goes on this will be all you want to do.
The passion for treating orofacial pain is one thing, however, getting paid is another. As I see orofacial pain practices around the country, I see doctors who are working for very little money because they are doing what is their passion, which is very commendable, and almost inspirational. When the question comes from your bookeeper as to how to pay the bills and keep the practice open, one must look at ways of at least making enough money to pay the bills. It
took years and years of work between my wife and I to figure out how to keep the doors open while still serving these patients in pain. I owe a lot to her for that. The profitability aspect of orofacial pain practice was what I hope to some day be able to pass on to others that venture into this valley on human need. Perhaps, after I find my associate, I will have time to put my thoughts together so that I can help other practicing doctors who responds to the call to help this patients in pain.