Doctor on Call: A reality check regarding electronic messaging and a potential solution to the “bigger problem”
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This particular communication came to me not as the magazine’s editor but as a treating physician-details have been altered to preserve confidentiality.
AP, a 48-year-old female attorney who lives and practices in Reston, Virginia, writes (or, more accurately, typed and hit “send.”…
Dr. R,
I have a 90-day prescription for 48 doses of X, and I use it when I have a migraine. I ran out of the prescription 3 weeks ago, and my pharmacy says it’s too early for a refill. Please send my insurer a letter explaining why I need an early refill and a prescription for a higher quantity. You can fax the letter to xxx-xxx-xxxx.
I also need you to send a prescription for injectable Y to a pharmacy near me which has the amount I need in stock (my insurer authorizes 16 doses per month). It is a Harris Teeter pharmacy in Great Falls.
I am having a lot of headaches and need your advice. Please call me after 5pm today at xxx-xxx-xxxx.
AP
The Doctor’s Reply:
Dear Ms. P,
I will attempt both micro and macro responses to your requests.
To summarize, you wish for me to prepare for you a letter that provides to your insurer a justification for why you should receive an early refill for X, a medication which you presumably are using at a frequency and in a quantity well above what typically is recommended for the acute treatment of migraine.
Along with this, you wish me to enter into your electronic medical record (EMR) information regarding your new pharmacy of choice, an action which you yourself are quite capable of undertaking via our MyChart system that allows patients access to their own EMRs.
Next you wish me to send to this new pharmacy a prescription for Y, another medication commonly used for acute migraine treatment, again in a quantity far exceeding what I typically prescribe, and, if used at corresponding frequency, at a use/frequency level considered unsafe.
Finally, you apparently wish me to call you today at a time convenient for you to, in essence, conduct a telephone consult for which my department will receive no financial compensation.
Your message lay nestled amongst 27 other similar messages awaiting me this evening when I finished my clinic. To address all of these messages in a professional manner will require 1 to 2 hours. In a prospective study we conducted 3 years ago, to do so on a chronic basis consumed a little less than 40 hours of my time each month. Over the ensuing years both the volume of those messages and the time required to respond has only increased.
I can easily understand that such electronic messaging and management is attractive for the patient, but in our current system of healthcare delivery this represents a tremendous and demoralizing time suck for the provider. Those hours spent responding to electronic messages are obviously not hours spent seeing new patients, educating trainees to practice at the existing standard of care, conducting research intended to raise the existing standard of care or, for that matter, spending time with our families or on our own physical and emotional health. Those extra hours spent do not generate additional financial revenue for our institutions, our departments or for us personally.
It is as if one day you were informed that you now will be expected to volunteer the equivalent of an extra work week per month, to do so without additional compensation of any type and to do so while still performing at or above your baseline level of productivity.
Have you read of “physician burnout“? Do you understand what effect it will have on American medicine – and the practice of headache medicine in particular – if physicians continue to exit the clinical workforce so as to retire early or accept non-clinical positions? Do you understand that they are doing so in their effort to escape the impossible demand that objective evidence of productivity be maintained despite ever-declining compensation from 3rd party payors, the dubious charms of the EMR and the widespread implementation of a system that provides patients with unlimited access to their providers...coupled with the expectation that this access be reciprocated - and promptly - despite the absence of any positive incentive for the providers to do so?
Let’s take a step back for a more macro view…
When I first began practicing headache medicine in earnest about 35 years ago, we had very few truly evidence-based therapies for the treatment of acute migraine or prevention of episodic migraine, and for chronic migraine we had not even an accepted diagnosis…let alone any evidence-based therapy. With my colleagues I have spent the past 3 decades assisting in the development of what is now an impressive arsenal of FDA-approved and evidence-based therapies, and it has been my sincere pleasure to have had at least some small hand in the development of virtually every new therapy for migraine since the introduction of injectable sumatriptan in 1992.
That’s great, but ironically this persistent revolution in migraine therapeutics - and the associated promotion of those therapies - has served only to amplify the long-existing supply><demand problem which adversely impacts migraine management: upwards of 30 million Americans are in need of medical attention for their migraine, but there exists only a relative handful of healthcare providers with the experience and inclination required to provide that attention.
For neurology generally we may be in somewhat better shape than, say, the Republic of Ireland, with its 24 neurologists serving the neurological needs of 4.5 million citizens. For headache medicine, however, we are sorely overmatched…and thanks to the decidedly mixed blessings of electronic patient-to-provider messaging, increased public awareness of migraine, continuous and time-consuming battles with the healthcare insurance industry and the indifferent or – at least - far off the mark stance taken by the for-profit pharmaceutical industry, this imbalance continues to grow.
Do you think my responding to your electronic message today and to the hundreds of others over the weeks that follow will help serve to redress this imbalance? Of course it won’t. The time physician sub-specialists in headache medicine must devote to unsolicited electronic messages is eating away at the supply side of the ratio and – trust me on this – seriously eroding professional quality of life.
Too bad for us providers, I suppose, but I see no relief in sight. We are now allowed to charge for many of the electronic communications we have with our patients, but the process involved in doing so is often cumbersome, and the net revenue generated is, to say the least, unimpressive. Charging for the service does not even seem to deter patients from enthusiastic use of this system: when Johns Hopkins implemented a “fee for message” paradigm, the volume of messages received by providers declined by a only few percentage points.
Taking another step towards a yet more macroscopic view, what exactly can we do about the persistent and increasing imbalance between migraineur demand and healthcare provider supply? This is ground we have traveled before in this magazine. To reiterate briefly some of what previously has been written, I would predict that even with an increasing number of headache fellowships producing well-trained physician headache sub-specialists, those new MD providers entering the medical workforce will do little more than offset the volume of those exiting.
Given the success we’ve enjoyed in developing evidence-based management strategies for migraine it’s certainly conceivable that AI eventually could come to the rescue: evidence-based management is a far better fit with AI than is practicing “the art of medicine”. AI-assisted diagnosis and treatment could provide patients and providers with entirely new options for managing migraine, greater access to effective care for many not currently receiving that care and a far more solid chunk removed from the burden on public health imposed by migraine.
In the meantime, however, what can we do to augment the supply side and increase the number of healthcare providers capable of/inclined to see and treat high high volumes of migraine patients?
For some years now my colleagues and I have been training advanced practice providers (APPs: physician assistants and nurse practitioners) to become highly competent in headache management and research. As research presented at national and international meetings and published in the peer-reviewed medical literature repeatedly has indicated, we and other investigators have demonstrated that appropriately trained APPs may perform at the same level as a physician headache sub-specialist in terms of clinical management, clinical outcome and patient satisfaction. We now have established at my parent institution, Inova Health/the University of Virginia, a first of its kind formal one-year headache medicine fellowship for APPs and are in the process of recruiting our first trainees.
To borrow yet again from Winston Churchill, our fellowship initiative does not represent the “beginning of the end“ for the migraine supply:demand imbalance, but it may help serve as the “end of the beginning”.
This, Ms. P, is what I suspect you and other migraineurs want physicians like me to be doing. Not seeing routine migraine patients in clinic and treating them with the same evidence-based therapies that we helped to develop while simultaneously responding to the never-ending torrent of electronic messages that arrive in our inbox, but rather to be training others to practice headache medicine at the same level of competence that we can, to be available to them should they require assistance and, released from the burden of “regular” clinical practice and “electronic tasking“, to use that now-available time to help develop new evidence-based therapies effective for migraineurs who have not responded to what already is out there for general use.
To reiterate an earlier paraphrase of a WC quote, this could serve as a path to the “sunlit uplands.”
