Curbside Consult with Dr. Jayne 7/24/23

I recently attended a gathering of physicians from across the US and was surprised by the overwhelmingly negative tone of most of the informal conversations. It seemed like the majority of attendees were exhibiting at least some level of burnout, ranging from frustration with daily processes to frank exhaustion from lack of organizational support for patient care.

During the pandemic, many of us were asked to do more with less. In many organizations, those work efforts have become part of day-to-day expectations. Just because physicians can work at that level doesn’t mean that they should, and when they have to do so, it should be the exception and not the rule.

I still remember those COVID-driven shifts when I was responsible for seeing over 100 patients. I would be deluding myself if I said they received the same level of care that they would have pre-pandemic, but we were all just doing what we could at the time. Pre-pandemic, a heavy shift would have been 60 patients, and that would have been with the support of a nurse practitioner or physician assistant. Now, my former employer expects providers (whether physician, nurse practitioner, or physician assistant) to all see upwards of 60 patients as part of a “normal” shift, reinforcing it with comments about how “at least it’s not as bad as it was during COVID.” Whether we like it or not, the baseline has shifted for many, and not in a good way.

I was deeply saddened to see so many of my colleagues sharing some fairly strong sentiments that were decidedly not pro-patient. Some were frankly anti-patient. I listened to a fair amount of victim-blaming, as physicians tried to rationalize broken elements of our healthcare system by shifting responsibility to the patients.

One of the strongest discussions was around the immediate release of laboratory and testing results to patients via patient portals. A physician discussed being contacted by one of their family members who wanted help understanding an imaging report. The write-up included a newly detected tumor as well as the possibility of advanced metastatic disease. Unfortunately, the reading of the study was completed at 2 a.m. on a Sunday, resulting in a “you have new results in your chart” text message that greeted the patient as they were getting ready for the day.

So much has changed about how health systems operate in the last few decades that have led us to situations like this. In my early days in practice, non-urgent studies weren’t read on weekends. They were typically read by the radiologists Monday through Friday from 7 a.m. to 4 p.m. The radiology group was often a small private group that was contracted with the hospital. I knew those radiologists at my various hospitals because we went to medical staff meetings together, saw each other at hospital auxiliary events, and communicated regularly about cases.

Hospital policies were in place that radiologists called the ordering physician for critical or unusual results or findings, such as a massive tumor with possible metastases. At that time, radiologists were relatively tethered to the hospital due to the limitations of imaging systems.

Fast forward to improvements in technology, where nearly all imaging is digital and hospitals looked to take advantage of outsourcing agreements and economies of scale in determining who interpreted radiological studies. Now our studies could be read by physicians in other time zones, with a larger window for results to be released. Unfortunately, the anonymity of those distant physicians made it less likely that hospital policies would be followed, and there certainly weren’t relationships in place that encouraged collegial discussion of our patients. The ability to work during non-traditional hours was also attractive to physicians, who might want to work overnight so that they were more available to their families or for other pursuits.

When taken by itself, each of these factors seems like a positive development until you realize that when combined, they have led to the current state where imaging tests are read 24×7, often by physicians who have no relationship with the ordering physicians. Add the 21st Century Cures Act and its information blocking provisions to the mix and it has the potential to become quite messy.

Some of the comments made by my physician peers included these: “Well, the patient didn’t have to look at it. They could have just stayed out of the portal until their physician called them.” I couldn’t believe what I was hearing. It was immediately followed by, “They should have changed their portal settings so they didn’t get a text.” Several people agreed.

I asked how many of them knew how to update those portal settings, if their practices offered educational materials to help patients through that process, and if they discussed that scenario with their patients when ordering high-stakes testing. They looked at me like I was speaking gibberish.

Another physician kept talking about the provisions of the CARES Act, which they had confused with the 21st Century Cures Act. None of them were aware that there are exceptions to the rules on information blocking in the 21st Century Cures Act.

In a nutshell, the Preventing Harm exception allows providers to block access to electronic health information if they believe the information will cause harm to a patient or another person, assuming certain conditions are met. I’ve seen health systems operationalize this in a variety of ways, most often allowing an ordering clinician to flag a diagnostic order so that the results will not be immediately released to the patient. This meets the conditions of the exception in that it can’t be broader than necessary – meaning that a physician can’t flag all of their orders – and it has to be done on an individualized patient basis.

I’ve seen templated phrases deployed to allow clinicians to document conversations with patients about whether to delay releasing test results. For example, “Discussed with patient that results may be available in the patient portal prior to my review. Patients may find this distressing and it may contribute to worsening of health conditions. Patient elects to proceed with immediate results.”

Or, “Discussed with patient that results may be available in the patient portal prior to my review. Patients may find this distressing and it may contribute to worsening of health conditions. Patient would like results held until the physician review and notification process occurs.”

I’ve also seen where ordering physicians can add additional detail on the kinds of harms that might happen, including worsening hypertension, worsening of anxiety or depression symptoms, etc. I don’t know if these are customizations done by individual hospitals or health systems or whether vendors are actually doing this.

Ultimately the results are indeed released to the patient, but they’re released in a way that meets the patient’s needs.

Most of the commentaries I’ve read say that emotional harm isn’t enough to block immediate release, that it has to be life-endangering or a risk of physical harm, but I think tying it in to potential physiologic changes for the patient makes sense. I would hope that federal regulators have enough to do without going after a physician who clearly documents why they delayed the release of a result after discussing it with a patient and clearly documents the conversation. I also suspect that patients who had their wishes honored would be less likely to file a complaint.

When I discussed these approaches with my colleagues, they stated unanimously that they were unaware of any way to block notification to a patient, even temporarily. They were all from different health systems, so I recommended checking with their IT teams to see if there’s functionality that they’re just not aware of.

Moving beyond the problem of patients seeing test results before their care team, the majority of the conversations fell into the theme of “medicine is going to hell in a handbasket.” Nearly all those present were exhibiting symptoms of compassion fatigue, including exhaustion and feelings of helplessness, anger, decreased professional respect, and powerlessness.

Technology seemed to take a lot of the blame, with plenty of focus on inboxes, patient messages, and EHR documentation, including prior authorizations and referrals. It should be noted the many of these existed in the paper world and technology has brought some efficiencies, but making that point didn’t seem to make a difference in the conversation.

Overall, the conference was a bit of a downer, and I left it feeling less than hopeful for the future of medicine. Regardless of how many healthcare resources each of us consumes now, as we age we’re going to need more resources, and I’m not sure we can get this system back on track. It’s tough to counter the forces that are causing people to burn out, and I’m not seeing a lot of organizations moving the needle in the right direction in this regard.

For patients who are on the downstream end of compassion fatigue, I feel for you. I’ve been there myself, and it’s not anywhere we want to find ourselves.

What steps is your organization taking to fight compassion fatigue? Are they allowing physicians to delay patient portal release on certain results? Leave a comment or email me.

Email Dr. Jayne.