Skip to main content

Table 1 Five domains of change in the current practice of medicine, and their potential adverse consequences**. First domain: time constraints

From: The Spectrum of Harm Associated with Modern Medicine

I. Short visits—rushed encounter
↓ Length of stay (hospital) or unchanged encounter time (ambulatory care) vs. more issues per visit: ↑ New, time-consuming tasks (e.g., patient-centered care; preventive services); ↑ Patients’ complexity (ageing, multimorbidity, polypharmacy); flooding of patient-related data (e.g., in the EHR); proliferating EHR prompts demanding attention; ↑ Options for tests and treatments beget harder decisions (see Table 4); ↓ Face time with patients, especially vs. ↑ screen time, (see Table 3); ↓ Communication; ↓ Patient-physician relationship/bonding; ↓ Attention to patients’ cues and concerns, or to nonverbal clues; ↓ Empathy; ↓ Communication skills; further ↓ In communication (vicious cycle); ↓ Patient-centered care; ↓ Time for physical examination; ↓ Clinical skills; ↓ Self-assurance and confidence; further ↓ In examination (vicious cycle); ↓ Satisfaction; ↓ Time for consulting databases or colleagues; ↑ Dependence on assistants (e.g., scribes, clinical pharmacists)
II. Physician burnout
↑ Demands for productivity—↑ workloads; ↑ Daily stress; ↓ Control over time and substantial decline in autonomy; ↑ Managerial scrutiny and supervision (cost, “defending” choices, quality metrics, patient satisfaction); ↑ Role of evidence-based medicine: downplaying individual experience and clinical judgment; ↑ Clerical and administrative duties; ↑ Remuneration concerns; ↑ Screen time vs. ↓ face time; ↑ Patient’s demands and criticism (see Table 5); ↑ Fatigue, exhaustion; ↑ Irritability, anger, conflicts; ↓ Teamwork capacity; ↓ Efficiency and productivity; ↑ Incidence of medical errors; ↓ Empathy, compassion, and humanism; ↓ Patient-physician relationship/bonding; ↓ Attention to patients’ cues and concerns; ↓ Sense of altruistic achievement; ↑ Guilt; ↓ Meaning; ↑ Distancing; ↓ Satisfaction; ↓ Coping; ↑ Attrition; ↑ Intent to leave and job turnover; ↑ Early retirement; ↓ Attention/time for personal life, personal health; ↓ Personal health (“self-care”); ↑ Marital/relations problems; ↑ Alcohol, smoking, substance abuse; ↑ Depression; ↑ Risk of accidents (driving, needle sticks), suicidal ideation, mortality ratios; ↑ Unprofessional behaviors —All creating a vicious cycle
III. Impaired clinical performance and quality of care (largely due to I. + II.)
↓ /Impaired decision-making; ↓ Adherence to clinical guidelines; ↓ Patient-centered care; ↑ Referrals of all kinds, including unnecessary imaging, tests, consultations, and procedures (see Table 2); ↑ Prescriptions, some unnecessary; ↑ Risk of adverse effects and iatrogenic harm; ↑ “Defensive” practice; ↓ Energy for consultation (databases, colleagues) to select appropriate test/treatment; ↑ Use of heuristics (“type 1, intuitive reasoning”) and bias; ↑ Diagnostic and other errors, and adverse events; ↓ Recommendation of evidence-based screening or healthy lifestyle; ↑ Readmissions; ↓ Patient safety; ↓ Patient satisfaction and adherence
  1. **Reported for every discipline (primarily, family medicine and general internal medicine) and setting, including hospital admissions. Domains’ effects are interwoven with each other. All contribute together to the “crisis,” “collapse,” or “chaos” (quotes) in current health-care systems