It takes a special person to care for people during their most vulnerable states, to keep intimate details about people while remaining compassionate even toward the seemingly vilest of persons. The white color of a physicians’ coat can be a metaphor for the purity expected of physicians. A physician’s signature or words carry weight. With such power comes the responsibility to be trustworthy.
Documentation is an important part of patient care. It helps other healthcare professionals know the patient’s medical history, treatment, and treatment response, which helps to determine the direction of further care or workup. Documentation is, therefore, not just for billing, but an integral part of delivering quality and safe care. Unfortunately, documentation and administrative requirements have become so cumbersome and time-consuming that it is usurping time away from direct patient care. Electronic health records (EHR) can decrease productivity, introduce errors, and negatively affect the perception of quality care. EHRs are also shown to decrease work satisfaction, increase the likelihood of burnout, and cause stress in physicians.
An AMA survey revealed that “for every hour physicians spend with patients, they spend 2 hours on EHR documentation and other desk work.” Researchers at the University of Pennsylvania and Johns Hopkins University showed that internal medicine interns spent about 43% of their day on indirect patient care, mainly EHR use, leaving just over half of their time to be split among direct patient care, studying, and other activities of daily living. A recent study found that, compared with hospitalists, specialists experienced a decrease in hospital malpractice claims rates and had relatively lower injury severity and indemnity payments. One explanation for this discrepancy may be the increasing (and unsafe) patient load that hospitalists are expected to see and the increasing associated administrative work.
Even so, is the drudge of documentation sufficient reason for the compromise of integrity in documentation and for forgetting the purpose of medical documentation. I have seen too many useless notes—notes dated for today but a replica of the note from prior days, right down to vitals, and containing medications that the patient is no longer on or lab requests that were already done and resulted. The result is a fragmented plan in which covering physicians must try to figure out the patient’s care plan and the rationale for certain orders. It makes work harder for the incoming physician, who needs to figure all this out before knowing how to proceed with the day’s care. I have seen too many physicians in different locations and facilities go into a room and within minutes come back to write or dictate full notes with complete exam, right down to examining the internal auditory canal, though no working otoscope is available. How about doctors who examine the relevant body system during a new patient visit, yet somehow document a complete physical exam with normal results except for whatever abnormality is noted in the body system of focus? This has made the physical exam report unreliable or something to be believed with caution. For a stable patient, the physical exam section may be irrelevant, but in certain cases— like in a patient with fever and unknown duration of murmur—patients may undergo unnecessary tests or even treatment with the attendant risk of complications.
Given the complexity of acutely ill patients, it still baffles me that some generalist physicians can see 30+ patients in a shift. Such physicians may be efficiency superstars, but at what cost? Are physicians blurring the lines of integrity to be a superstar? The documentation rules need to be changed so that physicians can be more in control of what to document, as they are the ones performing the cognitive work and who have the training. For instance, a complete physical exam is, in some patients, a hindrance to care. Imagine telling a patient with new-onset, left-sided paralysis that you need to perform a complete physical exam before they can go for that CT scan or get treatment orders put in. A complete exam as a requirement in an H&P is the stuff that belongs to annual physical visits or in the care of patients with unknown etiology of symptoms. However, because billing and compensation dictate having a complete physical exam, a complete physical exam is documented. Physicians worsen the burden of documentation by pretending that we can handle the unrealistic clinical and administrative work, while our integrity is being continually compromised; it’s a slippery slope.
Physician integrity in documentation is now especially important, as patients can view their own notes and spot the discrepancy between what exam the physician documented and what the patient remembers having done. We do not want to lose the respect of our patients for such things as assuming a normal exam. It is one thing to forget to document (or fully edit the template of) aspects of the physical exam that one typically performs on patients; it is quite another to document intentionally what one did not do in the slightest bit. “Normal” exams can change what we perceive to be a patient’s baseline; a chronic finding may be perceived as acute when compared with admission exam results, potentially leading to more unnecessary procedures.
The burden of the documentation and administrative tasks on physicians needs to be lightened significantly. While we await these changes, physicians should still aim to maintain integrity and avoid flirtations with fraudulent behavior. This helps our fellow physicians who takeover care from us, it helps our patients, it can help reduce healthcare costs, and it maintains the respect and reputation of our profession. If, for the sake of quality care and patient safety, a physician must see fewer patients than what their employers may desire from a financial standpoint, so be it. If multiple physicians cannot see a certain number of patients within the reasonable bounds of quality care and integrity, it might reveal unreasonable work expectations. With the rising rate of physician burnout, we must attempt to reduce contributors. We work hard for our patients and sacrifice for them. Let us continue to make the best decisions that we can with integrity.