During the past several years I have had the opportunity to work with leaders from several hundred hospitals and health systems, as well as the physicians on their medical staffs, and have come to understand the impact of a number of external realities on our profession. These realities are resulting in a diminution of professionalism and a pervading sense that we’ve lost something, that “something” often being identified as the “art of medicine.”
There are numerous contributing factors to this, including the loss of professional autonomy due to regulatory and contractual constraints, physicians feeling as though they are bit workers on an assembly line, billing requirements necessitating a focus on producing “bullets and elements” for E/M visits (rather than describing the patient’s condition), and perhaps most importantly, increasing constraints on the time physicians can spend with patients. In a recent report, 80 percent of polled physicians related that “patient relationships” are the most satisfying part of practicing medicine. Yet we see reports that 28 percent of an average ER physician’s time is spent directly with patients, and as little as 20 percent of a hospitalist’s on-duty time is spent in direct patient care. The rest of their time is spent doing “stuff” I didn’t have to do early in my clinical practice…
Valuable solutions in our industry, such as the electronic health record (EHR), present challenges as well. Many physicians state that EHRs not only decrease efficiency and cost them time, but that they can also interfere with face-to-face communication or accuracy of their recorded “professional opinion.” This is not an indictment of the EHR, but rather a realization that infrastructure has to be constructed before beneficial solutions can be implemented.
In addition to the above challenges, physicians now are faced with the transition to ICD-10. Is this a potentially career-threatening “tipping point?” Many would argue that it is, yet I’d like to share a more positive perspective. Essential to the art of medicine is the most professionally guarded attribute of a physician: the authority to make a clinical diagnosis. A physician’s “clinical impression” is derived both from the objective science of medicine as well as the interpersonal art of the doctor-patient relationship and insights into the nuances of body language, family input, “soft signs,” and the like.
So what does ICD-10 imply for physicians? The first thought is cost and loss of productivity. The cost issue is a given, and physicians have legitimate and significant concerns regarding the price of implementation. But from a clinical perspective, what is ICD-10, really? It is a far more precise clinical coding system that will support enhanced epidemiology, clinical research, and even individual patient care. If anyone doubts that last part, let me put it into perspective. If the additional specificity of ICD-10 provides no additional clinical value, then the same should apply to ICD-9. Why do we even need that level of specificity? Why don’t we just admit any patient to the hospital as “sick?” The reason is that clinical specificity drives appropriate treatment. Clinically speaking, we need the specificity of ICD-10.
As an educator, I often learn from my audience. Let me share with you an extremely insightful perspective of an internist at a recent presentation. Here are his words: “I get it. ICD-10 is really what we expect from our residents at morning report.” Exactly. When a resident presents a case with a general diagnosis alone, the attending physician typically inquires about etiology, clinical manifestations, anatomic specificity, laterality, and the like, which is exactly the type of information required for ICD-10 coding.
So let me come full circle to the issues of professionalism and the “art of medicine,” and how they can be impacted by ICD-10. Diagnostic specificity in ICD-10 entices a higher level of professionalism by requiring deeper inquiry into etiology of clinical illnesses and the correlation of clinical findings to those diagnoses. Very often, the art of medicine is utilized to derive that information.
Many other issues have to be addressed to revitalize the art of medicine, but ICD-10 should be viewed not as an impediment to professionalism, but rather as one aspect of its realization.
About the Author
Paul Weygandt, MD, JD, MPH, MBA, CCS, CPE, is a Certified Physician Executive (CPE) with more than 20 combined years of experience in medical management, legal counsel, and orthopedic surgery. He has served as a hospital VPMA, improving documentation across all DRG payers. Paul is vice president of physician services for J.A. Thomas & Associates (a Nuance company). He is also an AHIMA-approved ICD-10-CM/PCS trainer.
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