Mark Lopatin MD Rheumatologist

The Evolution of a Health-Care Advocate

This article from "Rheum for Improvement" from Doctor Mark Lopatin tells us how corporate medicine has changed health care from a human interaction between a patient and their physician. He tells us his personal story of how bureaucracy has changed the way medicine is practiced.

The Evolution of a Health-Care Advocate


Written by Mark Lopatin, MD

Let’s look at how documentation has exceeded actual patient care in level of importance. Documenting what you have done as a physician is essential, but it has gotten entirely out of hand. I have jokingly commented that my degree should be changed from an MD to a DEO, as I have become a glorified data entry operator. Getting the right answer no longer matters. Instead, the focus is on whether a physician has shown their work and appropriately justified the reasoning for a particular diagnostic test or treatment to a third party. Documentation that is unsatisfactory to a third party may mean denial of a particular test or treatment or result in, in adequate reimbursement. The electronic health record (EHR) has become nothing more than a billing tool. The price we pay is that the more time physicians spend documenting, the less time we spend engaging patients.

Documentation should be focused on explaining a physician’s thought processes, but instead the emphasis has been placed on quantifying data. For example, as a rheumatologist, one of the key things I must assess is pain. Pain is subjective and cannot be quantified using a 1-10 numerical scale. Physicians, however, are forced to use such a scale to satisfy one of the insurer’s criteria for reimbursement. The problem is that one person’s “8” is another person’s “2”. Furthermore, pain levels are different at different times, in different places, and for different conditions. Physicians are expected to provide one number at each visit to quantify a patient’s pain experience.

Physicians are also routinely required by insurers to not only provide a number to define a patient’s pain level but also to document if a patient’s pain is better or worse. The question is, since when? Since the initial diagnosis? Since their last office visit? Since last week? Since yesterday? How do I record the pain level for a given condition, if it is better than it was last week, worse than it was yesterday, and about the same as it was at her last office visit a month ago? How should I document improvement when the pain in one joint is better, but pain in another joint is worse? What if the pain from her rheumatoid arthritis is worse, but her pain from fibromyalgia is better? Am I expected to document the pain at each visit, in each location, in each time frame, and for each condition? The amount of time it would take for me to document all of that would preclude me from actually providing medical care. Time spent documenting measures such as this is time not spent truly caring for patients.

Even documenting the diagnosis has become difficult. Physicians must use an alpha-numeric code for each diagnosis, and the number of codes expanded from 13,000 to 68,000 in 2015. These diagnostic codes often must be specified based on factors such as onset of the problem, an underlying cause to the problem, chronic versus acute, with or without complication, left versus right, initial versus subsequent visit, and so on.


This excessive need for documentation detracts from physicians’ ability to care for patients properly.


The key word here is “excessive.” Documentation is important, but not to this degree. As noted by one physician, “Dr. Mom,” on the medical blog “Sermo,”

Am I the only doctor who is sick and tired of being told how much my time is worth? I have to justify my time and substance of visits for each payment. I am spending more time documenting my visits than I am seeing my patients.

If I see a patient for 30 minutes, I have to document for 30 minutes why I spent that time. I get the distinct honor of coding the assessments and then I get to code quality measures. AND LORD FORBID I DON’T —then I don’t meet the standard of care. Just whose standard is that?

Furthermore, much of the documentation is required for billing purposes, rather than patient care. Doctors Christopher Notte and Neil Skolnick have noted, “The patient’s chart, once considered a sacred text containing the key inflection points in a patient’s story, has become merely a filing cabinet in which to stuff every piece of data about the patient no matter how mundane or trivial.” The demand for documentation results in long computer-generated notes that contain little practical information. It is not uncommon for a 16-page progress note to contain only one paragraph of useful information.

We have seen tremendous advances in science and technology, but the take-home message needs to be that being a physician and caring for patients is inherently a human experience. This is where we need to be placing our focus, not on documentation for documentation’s sake. How a physician relates to their patient may well be the most critical aspect of easing the patient’s suffering and is not something that can be quantified. The corporate takeover of medicine is extracting the humanity out of health care at an alarming rate, resulting in unprecedented levels of physician burnout. I assert that the best doctors are the ones who genuinely care about their patients as opposed to the ones who know the most. Medicine needs to be filled with “H”s: Helping, Humor, and Humility as corollaries to Healing, but Humanity remains the most important “H.” Hopefully this message will come through in this book. The need for documentation is just one example of how humanity, and therefore health care, is being compromised.


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