The patient-centered medical home (ain’t what it used to be)

Advocates of the patient-centered medical home tout the desirability of having all of this information in a central repository, readily accessible, complete. Supposedly, such a system will drastically reduce duplication of services, reduce the likelihood of medical error, and subsequently cut the cost of medical care. Conceptually, it all sounds so good—too good, as the adage goes, to be true. more»

Read more in my latest entry on the Musings blog of the JAAPA Editorial Board here.

JAAPA is the official publication of the American Academy of Physician Assistants.

The clinical encounter: an about-face?

Gradually, over the past decade we have been replacing face to face conversation with virtual interaction through cybervenues such as FaceTime and Facebook. Somehow, our social intercourse has not been not the same.

Face to Face. This slender volume rests on the bookshelf, a remnant from one of my graduate courses in counseling. The course was run as an encounter group. Participants had to work out the particulars of their interactions. Some of it was rough going; some of it wasn’t pleasant. You had to be an astute observer of body language, tone of voice, facial expression. Some of us were pretty adept at guarding our emotions; others wore their hearts on their sleeves. We didn’t necessarily agree with one another, but we heard one another out — at least, those of us who chose to interact.

In a group setting mutual support evolves through empathetic listening. To do so, you must be physically and psychologically present in the moment.

Similar interactions take place every day in the clinical encounter. We clinicians spend most of our day interacting with patients in the physical realm. With the advent and widespread use of the EMR (electronic medical record), face to face time has dwindled. Now the screen competes for our attention. No longer face to face with the patient, we tend to miss or overlook those subtle clues inherent in posture, facial expression, and body language.

Third-party payers are now advocating telemedicine as the latest and greatest means to improve access to healthcare and trim costs. In turning our eyes toward the future, might we actually be performing an about-face, as our physical face time recedes into the sphere of virtual reality?

A picture may be worth a thousand words, a video transcript even more; but I question the degree of meaningful healing that can take place in a virtual universe.

Best of times, worst of times

Back in 1983 during my time in graduate school, I took a course titled Community Psychology. Admittedly, I remember little from it; but one concept has stuck with me over the decades of my subsequent career: there are always resources available in the community; you merely need to seek them out. more»

Interested readers can now peruse my latest Musings blogContemporary medical practice: The best of times, the worst of times — at the Journal of the American Academy of Physician Assistants (JAAPA) website.

JAAPA is the official publication of the American Academy of Physician Assistants.


“We need to have you upload your electronic signature into the EMR,” the office manager tells me. “I’ve got the file stored on my desktop. You can log in, and I’ll walk you through the process.”

I slide into the chair at her desk and log in to my account. “Click on the gear icon at the top of the screen to access the drop-down menu,” the office manager says. A few clicks later the upload is complete.

“Good, another task accomplished,” she says. “Would you like a cookie? I baked them myself: oatmeal-raisin-chocolate chip.”

“Thanks,” I say, reaching an ample specimen from the zip-lock bag on her desk. I push back in the chair and savor the first melt-in-your-mouth bite.

“How are they?”

“Wonderful! Just the thing for a mid-morning pick-me-up.”

“We don’t do a lot of treats in the office — everyone seems to be watching their weight — but it is nice to have a sugar boost every once in a while.”

Thoughtfully, I savor another bite. “You could consider addressing both of those issues by adding a cookie icon to the EMR drop-down menu,” I muse. “Anytime a staff member feels the need for a snack, they could log on, access the menu, click on the cookie icon and voilà! — an instant calorie-free pick-me-up.”

The office manager studies my face with a mixture of awe and disbelief. She opens her mouth, as if to utter a comment; then quietly closes it.

“The only thing is,” I add, happily munching the final few crumbs of my treat, “you would have to be sure to change the browser settings to accept cookies.”

Typewriters and tools

Fifty years on I can still effortlessly conjure up a mental image of the old black Underwood typewriter that sat in my boyhood home. My father had acquired it second-hand during his college years; and in his chosen profession he still put it to good use. more»

Interested readers can now peruse my latest Musings blogTechnological tools still require thought — at the Journal of the American Academy of Physician Assistants (JAAPA) website.

JAAPA is the official publication of the American Academy of Physician Assistants.

Full circle

When it comes to systematic medical record keeping, it appears as though we’ve come full circle, as yet another layer has been added to the cost continuum of our healthcare system: the medical scribe.

According to a recent New York Times article, A Busy Doctor’s Right Hand, Ever Ready to Type, the latest trend to surface in medical practice is employing technical scribes to enter salient data into the electronic medical record in real-time, allowing clinicians to maintain eye contact as they talk to their patients.

Dr. Michael Murphy, the chief executive of ScribeAmerica, a company based in Aventura, Fla., that supplies scribes to hospitals and medical practices, estimates that there are nearly 10,000 scribes working in hospitals and medical practices around the country, with demand rising quickly. At his company alone, the number of scribes deployed to clinics and emergency departments has risen to 3,500 from 1,000 in the past three years.

When I first started clinical practice 35 years ago, I learned how to talk to patients. Not only did I talk to them, I spoke with them and I looked at them when I was doing so. I learned to read facial expressions and body language behind their remarks. I learned to look for incongruities that told me something was amiss. Much of what I gleaned during patient interviews held me in good stead when it came time to formulate diagnoses. (Statistics show that after they’ve completed taking the medical history, 85  percent of the time seasoned clinicians have a fairly clear idea of what the diagnosis is before performing the physical examination.)

All of that changed with the advent and subsequent widespread adoption of the electronic medical record (EMR). Clinicians who elect to participate in EMR systems are forced to carry an electronic tablet, notebook or laptop with them from room to room to record the salient points of the medical encounter. But it takes time to enter this myriad data, often at the expense of meaningful human interaction with the patient during the visit.

Advocates of EMR point to the benefits of immediate and shared data retrieval as well as fewer medical errors. Yet anyone who has slugged their way through a day of recording such data understands what a tremendous burden it puts on both clinician and patient alike.

Of course, the bottom line in capturing these myriad extraneous data is that encounters can be billed at a higher level of service. This means more money in the clinician’s pocket and less in the coffers of the third-party payers.

One glitch yet to be rectified is the damper that the EMR places on the numbers of patients seen. Obviously, a clinician can’t work his way through as many patient encounters if he is forced to take the time to record all of the necessary data on the spot. As a result, many clinicians end up taking electronic charts home with them to complete in the late evening hours.

Now we are witnessing the advent of EMR scribes, trained to input data into the electronic medical record in real-time as they follow individual clinicians from one patient encounter to the next. Ironically, this allows clinicians to focus on patients as human beings, maintaining eye contact as they talk with and listen to them. At the same time it allows visits to be billed at a higher level of service; and at the end of the day, no one has to take any additional work home.

One might question the need for yet another person in the exam room. Although her presence clearly benefits the clinician, one wonders what impact it might have on the interaction between the clinician and patient. In addition, in this era of cost containment, one might question the additional fees to pay for the services of scribes.

As a practicing clinician, I never claimed to be able to predict the future; but this time round from where I’m sitting, I think I can read the handwriting on the wall.

The devolution of healthcare

As I search for a word to describe the workings of our contemporary healthcare system, “devolution” comes to mind. Yes, the system has evolved dramatically. We now enjoy instant communication at our fingertips in real time. We can peer into the human body with modern imaging technology at much higher resolution than ever before. Our surgical techniques are state-of-the-art. But somehow we have lost something of our humanity in the process. more»

Interested readers can peruse my latest JAAPA Musings blog post, newly published in the Journal of the American Academy of Physician Assistants.