Doctors and email

Dubner writes in Freakonomics today – So That’s Why Doctors Don’t Use E-Mail

But surely it’s in everyone’s best interest for patients to stay informed, right? For patients to do their own research, to ask lots of questions — especially of their own doctors — and so forth, right? Right?

Wrong. At least that’s what Hai Fang, Nolan H. Miller, John A. Rizzo, and Richard J. Zeckhauser write in a new working paper called “Demanding Customers: Consumerist Patients and Quality of Care.”

From the abstract:

Consumerism arises when patients acquire and use medical information from sources apart from their physicians, such as the Internet and direct-to-patient advertising.

Consumerism has been hailed as a means of improving quality. This need not be the result. Consumerist patients place additional demands on their doctors’ time, thus imposing a negative externality on other patients. … Data from a large national survey of physicians shows that high levels of consumerism are associated with lower perceived quality.

The ensuing discussion consists mostly of angry patients and defensive physicians.  While I did not read every comment, most of them missed the point entirely.

Several important issues pertain in understanding this study.  The first problem is to understand the constraints that most physicians feel.  Our payment system has no way to reward email, phone calls or long discussions.  As some discussants mention, we get paid for the visit, not for time (unlike lawyers, accountants, plumbers, etc.)  Therefore, any activity which requires our time is considered a negative by most physicians.  Email and phone calls are provided without billing.  Patients smartly would rather communicate without coming to the office – but we then have to donate our time.

Now we should take care of patients in the proper way, which would include emails, phone calls and long discussions about web searches.  Retainer physicians do that.  If we went to a time linked payment system, then we would see many physicians embrace email and phone calls. 

Why do physicians dislike "consumerism?"  While sometimes the patient makes a great discovery, often the patient goes off on a tangent and develops a strong belief in incorrect data.  We then must spend a long time discussing the reasons for what we want to do, and why the information is incorrect. 

Now the idea about quality might relate to "informed" patients demanding incorrect treatments.  For example, one form of consumerism is direct to consumer advertising.  If a patient demands a particular drug (which is inappropriate) and the physician takes the easy road and writes the prescription, quality measures could suffer.  The same could occur if a patient demands a test or treatment which has no indication.

This issue is much more complex than Dubner’s entry considers.  Physicians have the wrong financial incentives (blame CMS and the insurance companies), and patients may substitute inadequate physician attention with internet searches – which have varying quality.

We need to embrace email, phone calls and educational discussions – and the insurers should pay for our time.  Patients should be able to specify their time needs, afterall when I see a lawyer I understand that time equals money.  Why should physician time not have value?

Physicians do have a responsibility to take the appropriate amount of time with each patient.  This will include discussing internet information or TV ads. 

This discussion highlights one of the major problems with our current health care mess.  Physician and patient incentives are not aligned.  If patients paid for time, then we would get an alignment, and I believe patient care and satisfaction would increase.