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Patients need space to raise real issues or concerns
by
Jeffrey Millstein, MD
January 4, 2025
Millstein is an attending physician.
The patient’s check-up begins, as most now do, by sitting down and typing my username and password into a computer. After a kind greeting, I launch into the growing checklist of tasks called quality measures, which now define quality in the eyes of insurance companies who decide on how much doctors get paid for our clinical services. I carefully review the patient’s deficiencies — perhaps a missed vaccine, depression screening, a few routine blood tests. For many people, this list may include many more items. As of 2020, CMS had implemented 788 quality measures in various programs.
The long list of queries makes me begin to imagine myself as a chatbot and wonder if anything would be any different if that were the case. The visit agenda leaves little room for meaningful open-ended conversation, like a simple, “So how’s life going for you these days?” or “Do you have any worries or concerns about your health?” or even “How’s your family?” delivered with curiosity and concern. These are questions that create a safe space to raise difficult issues. Nonetheless, according to the modern quality dashboard — where there is no metric for listening — I have provided a perfect visit.
Sound familiar? These tasks are important for the health of our patients and the health of our practices — we must meet pre-determined quality goals at scale to secure the best payment rates from insurers. But pressure to complete them during office visits can often distract doctors from addressing what concerns our patients most.
Helping patients get age-appropriate preventive care is a laudable goal; encouraging vaccinations and screenings for cancer, serious illness, and dangerous behaviors helps keep people safe while preventing hospitalization and premature death. However, it may not be what patients need from their doctor at every encounter.
The exam room is where we form connection and trust with patients, and where we can conduct thoughtful problem solving. That is why doctors may instinctually resist any intrusion on the private moments we share with patients. The electronic health record is the most vivid example: an exam room albatross that, despite its many data storage, safety, and patient access advantages, has been maddeningly inefficient for doctors to use. “Quality measures” is yet another meddler that has wedged itself into office visits.
How can we move forward to a better place? Quality measures and compassionate care can co-exist. Measures should be addressed during visits, but only if they come up organically or require thoughtful discussion. Otherwise, support staff should attend to these items through pre-office visit preparation and external system outreach. This is already happening in our health system and others, and should be expanded nationwide.
I currently help develop and refine processes for health teams that reach out to patients through either the online portal, texting, or email to order recommended screenings and foster partnership around preventive health goals. This means patients will notice more messages from our practices, which may seem intrusive. But the idea is to remove a more insidious intrusion: checkbox tasks that compete for doctors’ attention during visits.
Private insurance companies, as well as Medicaid and Medicare, can also be a major part of the solution by maintaining current quality goals and paying doctors in a manner that acknowledges other less easily measurable components of quality. These could include communication skills, clinical problem solving, and accurate diagnosis.
Rather than payment for individual services, payments that cover a patient’s yearly projected primary care needs would allow doctors the freedom to spend time and resources where they are most appropriate. CMS — the largest U.S. insurer and the one whose policies cover our most vulnerable citizens — should continue to innovate and lead this charge.
I can think of many times in my own practice when forcing myself away from the computer or going beyond the list of quality measures helped bring up very important patient concerns — things that were difficult to disclose in response to a battery of questions, like a case of domestic abuse, minor symptoms causing a cancer scare, and worrisome obsessive-compulsive tendencies. Finding the time and focus to prompt patients to bring up these issues should not require fighting powerful incentives that do not belong in the exam room. All that is important in medicine is not measurable. We, as physicians, must offer our experience, expertise, and leadership to help reclaim our sacred space.
Jeffrey Millstein, MD, is an attending physician at Penn Medicine Woodbury Heights in New Jersey, and a clinical assistant professor of medicine at the Perelman School of Medicine in Philadelphia.
