Doctor on Call
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Amelia, a 25-year-old administrative assistant who lives in Philadelphia writes:
Dear Doctor,
I am really steamed! For the past two months I’ve been having a miserable time with my migraine, and when I send my doctor messages through the portal we are supposed to use as part of the electronic healthcare system to let him know that I’m having a severe headache or to ask questions about treatment, I typically receive a very brief and unhelpful response.
My chronic problem with his lack of responsiveness hit an all-time high last week when I sent him a message letting him know that I’d had a migraine attack severe enough to put me down for two days and cause me to miss work. In my message I asked him to provide me with a medical excuse for my having been absent from work, along with suggested accommodations for how my workplace environment could be rearranged to minimize my chance of having an acute migraine while on the job (different lighting, breaks to lie down, teleworking when needed, etc.). My supervisor at work is very demanding, and I needed that letter within 24 hours. His response: nothing!
What’s up with this? What do you do about a doctor who is simply ignoring his patients? Is this what medical care has come to?
Sign me: Furious in Philadelphia
The Doctor’s Reply:
Dear Furious,
First, I sincerely doubt that your doctor is “ignoring his patients”. It is far more likely that your electronic message containing multiple requests arrived when he was in the midst of a busy clinic providing direct care to a large volume of patients, late in the day when he was completing his clinic notes, or in the evening when he was at last spending some time with his family…or asleep.
In theory – and up to a point in practice – the ability for patients to access their medical providers via electronic messaging sounds great. In actual practice, however, it is fast proving to be the one of the leading banes of existence for many providers. I assume you are aware that the time providers expend on responding to patients electronically is financially uncompensated. When my research colleagues and I investigated the issue almost 2 years ago, we found that I was spending an average of 28 hours monthly simply responding to messages, de facto practicing medicine for free. I’m fairly sure that the time expended has only increased since.
And not truly free, really. Those hours represent time I otherwise could devote to providing clinical care to additional new patients, training medical students, residents and fellows, performing research intended to raise the standard of care for headache treatment and education…and, yes, to spending some time on myself to exercise, interact with family and friends, work in my garden, etc. I grant you that electronic messaging is a wonderful deal for patients. For doctors, not so much.
The study I referred to also demonstrated the interesting fact that a small proportion of patients generate a very high percentage of the messages a provider receives. At the extreme, I currently have in my practice one patient whom I’ve seen a total of 4 times in clinic, and over a period of 6 months I’ve received from her 67 electronic messages requiring some type of response. Although burdened by a chronic anxiety disorder and a great deal of personal stress related to marital woes and caring for multiple young children, she is by no means a desperately ill patient. In this circumstance, sending 67 messages in 6 months and as many as 8 messages on a single day borders on physician abuse.
I understand your need for a medical letter excusing you from work, but taking the time to compose and send that letter cannot take precedence over providing care to those patients who are sitting in the waiting area or exam room hoping to be evaluated in a timely manner.
As indicated in this issue’s “Tip of the Month”, no extra time has magically fallen out of the sky to assist providers in performing these electronic tasks. Directing patients who have sent electronically questions about their headache disorder and its management to come see me in clinic for a “traditional” evaluation doesn’t make much sense when the next available clinic appointment lies months in the future and there is a long waiting list of new patients who wish to establish care with me. Some institutions - notably Johns Hopkins - have begun to advise their patients that within certain parameters electronic, there will be a financial charge for communicating with a provider. If insurers refuse to underwrite that charge, it may be that the patient will be billed directly.
There are no easy solutions, but now that the genie is out of the bottle to which it is unlikely to return, we clearly need to find one.
In the interim, Amelia, please try to understand this difficult situation from the perspective of your doctor. Headache - and migraine particular – is a disorder that inherently is prone to generating a high volume of patient messages. Efficient communication with your headache provider can be a godsend, but please try to maintain a modicum of patience, be selective, and don’t overdo it.
