A New Paradigm in the Doctor

Patient Relationship How Technology Is Altering What We Thought We Understood

By Mikel D. Daniels, DPM, MBA, President and Chief Medical Officer, WeTreatFeet Podiatry

The doctor-patient relationship is dead, at least in the format we were all taught in school and during training. Today, there’s a moment, when you walk into an exam room that just didn’t exist 20 years ago.  It’s no longer just you and the patient. There’s a third presence sitting between you. It is the electronic health record (EHR), that often-maligned party, and whether anyone says it out loud or not, everyone in the room can feel it.

For most of medical history, the medical record was a prop. It was not an active character in the encounter. The paper chart resided on a counter or in your lap, waiting patiently, without the demands of a glowing screen, pings, required fields, or time-outs that interrupt a difficult conversation. In this pre-EHR era, physicians could maintain eye contact while making notes, and the workflow was intuitive, doctors would listen, think, examine, and then document. Although third-party payers were present at a distance, the conversation itself was clearly between 2 people. Despite existing pressures from short visits, prior authorizations, and relative value units (RVUs), the chart did not compete for attention. It sat there and it simply held the patient’s story. Then, almost suddenly, it evolved. 

When I first started in practice, my first boss told me about when he started in practice, his visit notes were written on 3 x 5 cards. He was at that time using a SOAP template. Two notes preprinted on a standard 8.5 x 11 in sheet of paper, and (I hate to admit this) most of his plans were just listed as “99213 or 99202” I have to say, it was horrifying. He retired before we started using an EHR. Can’t imagine how that would have worked for him.

Today, the EHR changed all of that. Not just by digitizing the note, but by inserting itself into the relationship as an active, attention-seeking third party. The long-felt feelings of patients and physicians are now confirmed. Unfortunately, today physicians spend significantly more time looking at screens than they ever did looking at a paper chart. This results in a bit (maybe a lot) less time looking directly at patients. Problematically, many clinicians feel EHRs worsens documentation time and drain their energy. Many physicians, often more than half in some surveys, report a negative impact on time and workload. The computer’s physical presence effectively “triangulates” the encounter. This is the new part of the doctor-EHR-patient relationship. Many patients often perceive it as an intrusion into what should feel like a private human exchange.

This intrusion manifests itself in subtle ways. The patient starts a story, the art of taking the narrative and translating it into a subjective complaint. While the patient is pouring out heart and soul (sole in my case, but I am a podiatrist) the physician’s gaze flicks to the allergy field that’s still blank. A difficult disclosure can be made, and sometimes missed as the physician is entering data, and watches while the hourglass spins. The physician’s hands are typing while the patient is trying to read their face. The quiet, and often not discussed dangerous part are the micro-behaviors patients show. These subtle signs might tell a different story, maybe the patient gazes off more often looking for words to describe the problem or doesn’t complete a thought due to more interruptions. All while there is more multitasking by the physician. The visit still happens, but the quality of presence is thinner. The third party that used to be “insurance” is now embodied as a screen full of required fields, alerts, and billing prompts. All of these are visible, all urgent, and all sitting between the physician and the person who came for help.

Care itself hasn’t necessarily been documented differently (for some doctors), but it’s been fundamentally re-engineered. One of the big shifts is moving from narrative to checkboxes. The long, coherent narrative of a paper note has been sliced into discrete, billable elements (remember NLDOCAT), problems, orders, quality metrics, and structured fields. While EHRs can improve certain aspects of care, like medication safety and guideline reminders, its primary effect is pushing clinicians toward template-driven thinking. You are no longer just telling the patient’s story; you’re satisfying the story the system needs. Now you are getting paid not to treat patients, but to document that you treated the patient. Sorry, but it’s so cynical.

The next devastating change is the swap from listening time to screen time. Eye-tracking and video studies confirm that physicians now spend a large proportion (even the majority) of the visit looking at the computer. This leaves less uninterrupted face-to-face connection. Ever had a good conversation in person when the other party was always looking away? This new paradigm is shaping the future of medicine. Today residents and interns are now logging staggering hours in the record, literally learning medicine through a screen. In my world, this translates into treating test results, not treating patients. Think bone sticking out of a toe, and ordering an MRI to see if there is osteomyelitis?

Finally, we’ve moved from “with” the patient to “about” the patient. The record shifted from a backstage tool to a front-stage actor. Sharing the screen can sometimes deepen engagement, but the problem is that the EHR is rarely used as a shared tool. Not to mention, then you are often forced to explain every checked medical term to a patient that wants to debate the merits of that choice. The chart note is now a private portal for billing, compliance, and risk management. The simple, and harsh truth, is that the EHR didn’t just join the visit. It has become the main audience. Notes are written for auditors, payers, quality programs, and malpractice defense, with whatever is left over for the patient or the next clinician. The patient is present, but the record is who the doctor is treating. The problem is that most of the time, the EHR isn’t used as a shared tool. It’s used as a private portal into billing, compliance, and risk management, and the patient watches the top of a bent head instead of the eyes of their physician.

Underneath all of this is a simple truth, the EHR didn’t just join the visit; it became the main audience. Notes are written for auditors, payers, quality programs, malpractice defense, and only secondarily for the patient or the next clinician. The patient is present, but the record is who the doctor is really conversing.

AI: Fourth Wheel or Quiet Ally?

Now, entering into this already crowded room, we’re adding Artificial Intelligence. AI can often become another voice, another party entering into the doctor–patient relationship. A well programmed and customized system actually might hold the potential to be the invisible assistant that the EHR should have shipped with in the first place. It offers a genuine opportunity to help. But how and what are the drawbacks?

AI can free the clinician’s eyes and hands. AI-powered scribes can listen to the visit, generate the note, and drop it into the record, all with minimal correction or attention. This crucial shift returns time and attention back to the patient. With the physician no longer typing, they can finally sit back, lean forward, watch the patient’s face, and actually listen. Early tools already deliver on this promise by summarizing histories, pulling meds and labs into records, and even drafting letters in plain language after the encounter.

This could sharpen physician judgment, but could it replace it?

AI systems are becoming adept at flagging risk, recommending diagnoses, and suggesting relevant guidelines. From allergy alerts to imaging comparisons, this is entering the doctor patient relationship. This capability doesn’t make the clinician obsolete, but it simply makes the cognitive load more manageable in a data-drowning environment. Used wisely, this efficiency allows the physician to spend more time explaining conditions to the patient. Ideally, this will result in significantly less time hunting through tabs, PDFs, and button clicking.

Turning The EHR Into Something Patients Can Actually Use

AI has the ability to translate dense, clinical data into human-readable narratives. It can then tailor education to a patient’s specific conditions (even translating from medical jargon to common language) and keep remote monitoring streams from becoming unmanageable noise. When patients can see and understand their own information, in language that feels human, the record transforms from a black box back into a shared education tool.

There is, of course, a catch. If AI is owned, designed, and deployed primarily to serve the same interests that shaped the EHR in the first place (documentation, billing, and control), then it will only become a more efficient way to automate all the wrong things. This will inevitably, bring us back to the other third party in the room.

Using This Technology, Myself, I Have 3 Main Problems

First, there are times when AI just makes stuff up. Called hallucinations, the AI can hear a patient say something and alter the significance of that problem in the medical record.  As an example, I ask all my diabetics about their control and numbers. The EHR (sometimes) makes that a primary diagnosis, and lists treatment options and programs, and includes information about diet and lifestyle that I didn’t discuss and make recommendations on medications.  Fortunately, you can tell most systems not to do that. However, if you don’t pay attention, your EHR could be putting sliding scales into your high-risk diabetic foot care visits.

Second, and what I consider my bigger problem, is that with AI, documentation is often completed at a later time. Since all I need to do is proofread the note and sign it, I might do it tomorrow. By then, I might have forgotten about the patient, the visit, or maybe a small detail that was important, but the AI missed. To combat this, I put reminders in the EHR so when I complete that note, I make sure it is listed. However, if I am putting items in the EHR, doesn’t that defeat the purpose of the AI?

Lastly, for this to work, you need to verbalize physician findings. Ever been in the middle of an exam saying palpable pedal pulses 2/4 bilateral? If you did, patients often start saying “what does that mean” or worse, disagreeing with your physician assessment. Can you really afford to take the valuable minutes you are spending with the patient and explaining a normal finding in plain English?

What about 3rd Party Payors and Insurance?

Third-party payors have been warping the doctor-patient relationship for decades, primarily through delays, denials, and an endless appetite for documentation. The EHR gave them a direct pipeline into the exam room, and AI is about to change that relationship again. This will likely occur in a few key directions.

The first is a move toward automated prior authorizations vs automated advocacy. AI tools are emerging to help payors streamline prior authorization, utilization management, and payment integrity. So essentially scaling their ability to approve, deny, or question care. Simultaneously, provider-side AI can instantly assemble clinical evidence, generate appeals, and optimize coding to capture revenue. The result is a new kind of negotiation. AI agents on the provider side talking to AI agents on the payer side, often faster than humans can even keep up. We all know that when your computer freezes, restart it. Can AI restart itself, or will our claims get stuck in the hourglass screen of death?

The second direction is a shift from opaque decisions to explainable friction. When a claim is denied today, the reasons are often buried in jargon. AI has the potential to make both sides’ logic more understandable. It can tell exactly which criteria aren’t met, what data is missing, or what alternative pathway is available. That transparency could either build trust or simply reveal how much of the system is designed to say “no” as cheaply as possible.

AI offers a chance at shifting the emotional burden. If these systems handle much of the back-and-forth, checking coverage, suggesting alternatives, drafting appeals, the physician can spend less time as the messenger of bad news (“your insurance won’t cover this”) and more time as an advocate, helping the patient navigate choices. However, if AI is deployed primarily to tighten payor controls, it risks deepening the sense that both doctor and patient are playing a rigged game run by algorithms they don’t control. Another party in the doctor-patient relationship.

Now, if I were an insurance company that wanted to streamline this process, I would do what car insurance companies are doing today. See the car insurance apps that are developing ways to track how you are driving (how it knows if you are driving or just a passenger beats me).  They know how fast you drive, how quick you stop, how long you go without stopping. They use this data to set your rates. Imagine if the insurance company gave you a free AI, and this determined all your billing and documentation needs. Maybe claim adjudication would be sped up? Not sure that is a desirable goal of an insurance company but would be a game changer.

Today, tension is already visible in the market. Investors are throwing money at the expanding opportunity in AI tools designed specifically for payors to optimize risk adjustment, payment integrity, and prior authorization workflows (ie, deny payment). This projected rapid growth is a clear signal that without deliberate guardrails, the same technology that could liberate clinicians may instead super-charge the administrative machinery that exhausts them.

The core question at that time isn’t simply “Will AI help?” but “Who is AI primarily serving in this relationship?” If AI’s main job is to reduce clicks, shorten documentation, surface clinically relevant information, and remove the physician from low-value fights with payors, then the doctor-patient relationship stands a chance not only surviving, but might even recover some of what’s been lost. If, instead, its primary job is to algorithmically deny care, optimize billing against outcomes, or watch clinicians for productivity and compliance, then the room just gets more crowded, and the patient is pushed even further to the edge of the relationship.

The relationship started as a conversation between 2 people and a quiet paper chart. The EHR pulled a fluorescent third chair up into the treatment room and demanded basically all of the attention. AI now gives us a rare chance to decide who that third chair really belongs to. Used well, it becomes the mostly invisible colleague who takes the notes, deals with the bureaucracy, and lets the human beings in the room look at each other again. Used badly, it becomes the new face of the same old pressures. AI would be just a faster, quieter, and harder party to argue with. The technology is here either way. The choice, who it serves, and who it answers to, is still up for grabs. Under any of these circumstances, the doctor-patient relationship is dead.  Which third party remains, the EHR or some new AI “colleague” remains to be seen.

Dr. Mikel Daniels is a board-certified podiatrist and healthcare executive with more than 2 decades of experience in foot and ankle surgery, wound care, and medical economics. As President and Chief Medical Officer of WeTreatFeet Podiatry, he has grown the practice from 1 office into a regional network of surgical centers and retail health services across Maryland, Pennsylvania, and Washington, D.C.

Dr. Daniels earned his Doctor of Podiatric Medicine from Temple University and an MBA in Healthcare Administration, combining clinical expertise with business strategy to deliver efficient, patient-centered care. His work focuses on complex reconstructive procedures, diabetic limb salvage, sports injuries, and minimally invasive techniques designed to accelerate recovery.

A Fellow of the American College of Foot and Ankle Surgeons and the American Professional Wound Care Association, Dr. Daniels also consults for biomedical technology firms and serves as a principal investigator in clinical research. His insights have appeared in Forbes, Parade Magazine, and CNN, and through his writing and mentorship, he continues to advance innovation and value-based care in podiatric medicine.