All patients will soon become e-patients

Just my .02– I don’t think of myself as an e-patient. I used the internet for research when I was diagnosed with ductal carcinoma in situ, but I am not accessing online records or exchanging e-mails or anything like that. I mean, I e-mail and text my husband all the time–am I an e-wife? I still think of myself as a patient, even if I start using more communication vehicles. I know the other part of the “e” often refers to empowerment and I totally get that we should take more responsibility for our health and advocate for ourselves. I’m sure that’s even more important if you have a chronic condition. I’m just beginning to wonder why we’re all spending so much time on semantics.

This was a great post, and I hope the discussion continues. Daphne, I can’t wait to see your thoughts on these issues going forward.

” I’m pissed and I want answers.”
“So, don’t call me a patient”
“I’m a frigging e-patient armed with information that not even my doctors have 90 percent (yes, 90 percent) of the time. Appalling, but true.”

“For now, providers—and others—beware”

These statements are not conducive to the doctor patient relationship. It is not supposed to be a power struggle. Because I am also “empowered”, I would remove myself from this patients care.

Taking care of patients who

I’m not a provider, thankfully, but she said “others” [beware], so I’m kinda scared…in case ‘others’ refers to M.D.s, and is not a clever reference to ‘Lost’.

Sounds threatening. I don’t do threatening. I certainly won’t be calling you ‘patient’! Or anyone else, for that matter, who thinks threatening and talkin’ trash to doctors is OK. Not in outpatient, ever, and rarely in inpatient. You are MORE than welcome to seek help elsewhere. Nobody’s stopping you. —–> Door.

There’s background, and then there’s literature. They are not interchangeable and should not be mistaken. Internists have background. It’s what you pick up in 7 grueling years of training and tens of thousands of hours of clinical experience. Literature is composed of studies. It’s what is picked up on the internet and in journals. They are nice, and improve care, but 99% of the time an individual study is unnecessary, and most physicians read the 1% of “high impact studies” that are. That the author finds some information somewhere that her physicians are unaware of is hardly appalling. They were most likely too busy seeing patients to keep up with every

“Do I get my money back if you don’t know how to treat my condition?”
Do you get your money back from a mechanic if he can’t fix your car? No, because it takes a tremendous amount of time and energy until you can finally say that you don’t know how to treat something. Your health is not a gimme; for those that think it is, please see my comment on impossible and unrealistic expectations. We do the best we can, and aggressive attitudes towards those of us who exhaust ourselves trying to help is not beneficial to anyone.

I have to do something here I’ve never done before, and hope never to do again. I want to take back a comment I made here. Not take it back exactly, but I have to confess to being guilty of pandering. When I first read Daphne’s original blog posting, my response on her blog was more true to who I am. I had tackled a similar issue on kevinmd, comparing patients to consumers, in which I came down pretty squarely on the side of doctors. I mentioned in my reply to her then that the word “patient” seems to have become synonymous with subservient.

After that original post, Daphne posted a nice reply to my comment and started following me on Twitter. And I think it went to my head. So you may have seen my earlier comment here saying “Great post! Can’t wait to hear what else you have to say!” Because I’ve gotten some positive attention from Daphne, I wanted to be positive in return, but I fear it made me sound more “Power to the people!” than I really am. It’s still true that I want to hear what else Daphne has to say about these issues. But if I had it to do over again, I would have said, “Thought provoking post” instead of “great” because “great” implies I agree with everything, and I don’t. I really do believe too many of us are beginning to view doctors as the hired help. I also believe that is wrong and erodes trust, as I said in my patient/consumer kevinmd post.

I see a lot of anger on both sides, and that bothers me. Daphne is catching some flak from doctors, and I caught a pretty massive amount of flak from patients on my consumer post. And I can handle that. But I can’t handle myself being so two-faced. My apologies.

I would like to mention 2 specific thankfully small subsets of patients who present for care having done so much research that they are terrified of all pharmaceuticals. With the caveat that I practice independent outpatient psychiatry and do not give out brand new medications and instead wait for the post marketing to settle out, these two groups of patients are maddening to treat (but you do have to let people choose…).
The first group are those who smoke marijuana multiple times per day and are philosophically against pharmaceutical drugs of any kind. Upon inquiry, they disclose that their marijuana is not organic and they do not know who or how it is grown. They are not disturbed by the proven effects it has been shown to have on the body as they consider this to be government propaganda. That the marijuana could be feeding the crippling anxiety for which they seek treatment pales in comparison to what they have read about the FDA conspiracies to collude with Big Pharma to cover up problems with drug trials. These patients are not paranoid schizophrenics.
The other group is between 50 and 65 and is deeply suspicious of all Western medicine because of all that web research and because “I know my body better than a doctor does”. I should hope so. However, they think nothing of paying $300 out of pocket for Chinese herbs and acupuncture treatments though they can not begin to explain how these treatments work or how to gauge if they work. This is the Seattle e-patient Boomer-style. Gotta love it.

Alina: You make a most excellent point. Listening before reacting — it’s a good skill, difficult to master.

Back up to Kathleen, I second your wise call to action, particularly where dropping ego-centered fear is concerned. Also, a difficult skill to master.

The good ones out there do it, though, and everyone is in a better place for it.

Daphne

IndiepsychNP: I’m proud of my professional role, as I’m sure you’re proud of yours. While there are certainly healthcare marketers out there whose motives are questionable, we are not all in the category of the unwashed and unwanted (just as not all physicians are paternalistic and condescending). I’ve been quite transparent, and the fact that I’m a marketer does not make me any less an “e-patient” or a human being, nor does it prohibit me from having an opinion (just as being a medical professional does not prohibit you from expressing your disagreement).

We obviously need more people speaking out for patients, and if that’s considered a “ploy,” then so be it.

Thanks for your comment and your perspective-
Daphne

I am a psychiatric nurse practitioner trying to shed some perspective for those who are disgruntled with primary care doctors and also explain some of the financial pressures on younger practitioners of all types which have lead to this current situation. Let’s use my situation as a teaching moment to examine the reality of insurance fees, students single handedly changing fees at teaching institutions or picking less expensive schools.
First, nurse practitioners do not receive any Medicare funding for their training. There is an estimated shortage of 45,000 psychiatrists at present. Primary care complains about reimbursement, but they should check out psychiatry. Likely due to the downward pressure on reimbursement over the last 30 years, the bulk of psychiatrists are baby boomers whose mean and median ages are 60 and 62 according to AMA survey data. I have completely independent practice in my state and am paid $5-15 less per time based billing code than psychiatrists. We can not, nor would I, short shrift patients on the amount of time I spend with them. We can not bill based on the severity of the illness or on any of the coordination of care or how elaborate the history taking is or how much time we actually spend. However, due to Congress’ lowering of the payment formula by Medicare once in the 80′s and once disastrously in 1996 reimbursement for psychiatry is far below that of any other medical specialty.

The result is that long before the current threatened cuts to Medicare rates by 21%, it is nearly impossible to find a Medicare provider unless the patient is disabled due to chronically mental illness and gets care AND has as state Medicaid coupon as well as Medicare. This leaves the elderly, even with Medigap, in most place without access to psychiatry particularly if they are in a rehabilitation facility. Medicare patients are the most time consuming and require the most coordination with other medical providers and with their family. This is what happens if providers only take insurance they are comfortable with. It took me 4 years in private practice to finally swallow my ethics and drop Medicare. If the government doesn’t value what I do, I can’t fight them on it.
For that matter, I could not fight the ivy league university I trained at over their fees. Located in New York City, it is closely affiliated with one of the preeminent psychoanalytic institutes where I trained. I’ve lived in Texas as a child (where nurse practitioners can’t prescribe independently). I wouldn’t go back on a bet. But more to the point, not everyone can go to state institutions for medical or nursing or PA school. It is a straw man argument when it comes to the problem of student loans. There are a lot of complicated reasons why the price of all higher education has skyrocketed in the last 30 years just as wages in the US has stagnated. I am not going to into it here with you.
As for providers’ fees, I wonder if you understand all of the incredibly obfuscated columns on the EOBs you are reading. Providers can charge whatever we want, but we are paid whatever the contracted rate is. This rate which in my state at least can be changed without notice by the insurance company. So I could tell you what I charge for a certain code, but it would be meaningless, because each any every plan under each and every insurance company pays me a different amount. The difference between the two is called a “contractual write off”. I give a discount to those who pay in full on the day of service because they are uninsured or have security clearances such that they do not want to use mental health benefits. As I cannot afford office staff (and even if I could) I will always give a break to the uninsured and would do anything to avoid billing.

And, yes, since we are all patients and voters in a what you feel is an influence-able democracy, contacting your representative about how much the training of health care providers costs is your responsibility because we all pay for it in the end.

As for what my responsibility as a health care provider is regarding your health care insurance? Absolutely none. However, last year I had many long term patients losing their jobs at the rate of one to two per week for weeks on end and therefore losing health insurance. I continued to see most of those patients for the cost of their co-pays while my stay-at-home husband and 2 children scrimped by on all of our savings. I signed them up for programs with drug companies for free medications. However, when they found employment again just enough of those same patients were unwilling to inconvenience themselves if the commute were longer to my office or they had to pay $25 more per visit because I was out of network with their new insurance, etc. that I re-examined what my responsibility to my patients is versus my responsibility to myself. I don’t at all regret giving away the care. But it made me think that since I am the one doing the caring regardless of whether I get paid I should try to get paid more fairly more of the time by companies and patients. Especially when most psychiatrists in this city do not take insurance at all.

But, yes, your insurance is yours and you have to get your employer to get you better coverage if you do not have good coverage. That should be easier than influencing tuition rates at a university. But as I said, insurance companies have followed Medicare’s lead and will no longer pay medical providers to provide E&M which means “education and management” which means explaining things to patients. Physicians can’t afford to hire RNs who understand disease processes to do this for them. That is why you are getting such brief visits. I am not reducing medical providers to technicians, but this metaphor for the payment structure might help you understand the situation. Imagine you are paying for a tune up on a Japanese car. There is an hourly fee for labor. You ask to have the whys and wherefores of the tune up explained to you. If you want to pay for the time to have it explained, it will cost you. The greed of insurance companies set up this absurd situation.

Being a medical provider is not like being a monk, priest, or nun. Our savings accounts run dry at some point.

Nice point, Martin. Thanks for chiming in here.

Daphne