Letters to the Editor

Decreasing work hours

ACP InternistWeekly and ACP HospitalistWeekly quoted a JAMA article saying that doctors have cut their work week from 55 to 51 hours (“Lower pay drives doctors to cut hours, “ March 2/3, 2010). I have a pretty strong opinion on this. I work in an office about 80% of the time. The other 20% of the time I work in the hospital. Since I don't believe there has been a new office internist in the U.S. since about 2004, I am sure that these changes reflect not lower hours from new hires so much as changes in the work activities of currently employed internists.

My career prior to medicine was as a computer programmer so it's not like I'm anti-technology. But my patient hours in the office have shrunk considerably since we started using an electronic medical record (EMR) system in 2006. My work week has expanded because, beginning this year, I spend more time completing charts and filling out forms than seeing patients.

In our clinic of nine physicians, every single one has had to cut patient contact hours to serve as our own transcriptionists and data entry personnel for the insurance companies. For every hour that I see patients I spend about an hour and 10 minutes filling out the multitude of boxes in our EMR. The largest staff-model HMO in our area shows physicians logged in for 102 minutes for every 60 minutes of patient appointments. They use a different system and have a fuller complement of information technology staff, lowering their salary but improving the computers' responsiveness and usefulness, I am sure.

For those of us who use office visit notes, the EMR has been an opportunity to do every bit of clerical work that can possibly be crammed into a screen, using the cheapest, slowest technology that meets the government guidelines. I am sure that this is a net savings for the system, which is then able to lay off transcriptionists and probably streamline accounting. What a cost savings to have physicians who get paid by the visit do more and more and more work to get the relative value unit of about $21 an RVU, which takes me 30-40 minutes to earn. I am making about $40 an hour, which is about one-third of what an accountant charges me.

Lynn Bentson, FACP
Albany, Ore.

‘The annual’ and HIV

We read your article “Rethinking the value of the annual exam, “ [ACP Internist, January 2010] with great interest and would like to offer a few comments.

Medicine is an ever-changing practice, with some practices having more of an evidence base than others. Although studies have shown lack of efficacy of the traditional annual history and physical examination [Arch Intern Med 1999; 159: 909-910, Arch Intern Med 2005; 165:1347-1352, Arch Intern Med 2005; 165: 1333-1334], a main argument in its favor is to maintain a patient-provider relationship and allow an opportunity for preventive measures such as education and targeted screening.

This is possibly true for many general practices, which have less contact with their patient population (i.e., 2-3 or less visits per year). However, some practices (such as ours, which cares exclusively for HIV-positive persons) have become a hybrid of specialty-primary care. Over the years, particularly during the last decade due to more efficacious HIV treatments, HIV-based practices have had to move from an acute care/progressive illness model to a clearly primary care-based model. This has been due to multiple factors such as a necessarily close relationship between patient and provider for long-term adherence promotion on complex regimens, frequent visits (between 3-6 visits per year based on guidelines) to monitor treatment efficacy, and managing long-term toxicities such as metabolic and renal disease as well as dealing with an aging population. In fact, in HIV-based practices, the current recommendations cover most preventive/health maintenance tasks such as smoking and substance abuse cessation counseling, STD education and screening/treatment, diabetes and lipid screening and management along with recommended vaccinations during regular visits. Therefore, the annual exam doesn't serve any additional health maintenance purposes in this setting.

Even further, with an electronic medical record-based system of care, targeted date- and age-sensitive automatic reminders for health maintenance items (vaccines, cancer screening, etc.) allow patients and providers to be kept up to date continuously without relying on an “annual exam” to complete a long list of maintenance items. It is very important that guidelines by ACP and the USPSTF reflect these nuances, as many other policies and standard-of-care measures are based on these recommendations. It should be noted that in specific settings, such as HIV-primary care practices for example, the annual history/physical requirement should be eliminated.

Homayoon Khanlou, MD
Paul DenOuden, ACP Member
Los Angeles