I very much hesitate to comment even briefly on the state of practicing medicine in the U.S. My outlook is that of just one foot-soldier in one particular place and setting (one that I thoroughly enjoy). Better minds and broader experiences are certainly available. Likewise, I do not want to appear to be whining when I feel so incredibly blessed to do what I do. Yet it seems that a brief perspective might be of some help, though I wish it included more solutions. Besides, my 88 year-old father-in-law who I deeply respect, has nudged me to do so.
In the thirty or so years that I have been involved in medicine, there has been an acceleration of some trends, especially in the last couple of years. In short, we are being slowly buried by an avalanche of bureaucratic minutia. One result of this is that the time it takes to document a visit has been substantially growing to the point that it threatens to squeeze out the actual time with the patient. And the notes are not better for being longer. Indeed, the multi-page computer template-generated notes that I get from consultants (or generate myself) rarely convey the kind of to-the-point helpful information that the prior shorter dictated notes used to contain.
There is a point where more is not better – where it becomes a near impossibility to wade through the sheer volume of words and data. Recently I sent a patient with low back pain to a consultant. I got back a 9 page single-spaced tome meant to communicate a fairly straightforward clinical impression. And I don’t really blame the consultant. He is trying to make sure his notes satisfy insurance companies who want to question his billing and judge the quality of his care from their remote locations, legal experts who could threaten his practice, and government authorities who might do both.
Let me just describe a typical office visit. A middle-age businessman comes in with abdominal pain. What I really want to do, and still try to do, is give him my full attention. Not only is that the right way to care for another human being in distress, but it is also the best way to hear the story clearly, complete with non-verbal cues, and arrive at an accurate diagnosis. Yet, at the same time, I know if I am not typing out the note while he is talking I will have to carve out time for that note somewhere else. So my computer is demanding my attention and eye-contact. Besides, I can’t order the labs until I have the appropriate diagnoses typed in to justify them.
Now maybe I need an abdominal ultrasound. We may have to stop everything and call the insurance company (and hope we get through in a reasonable time) to get them to approve the ultrasound. Of course we need to be sure the facility doing the ultrasound is on the patient’s insurance and hope that the radiologist is as well.
Perhaps my patient with abdominal pain needs a medication. Will his insurance cover a brand name? Is there a generic available that is close enough to the brand name to be worth trying? Now have I documented enough bullet points in the note so that the level being billed is properly supported? And we have only brushed the surface of all the little bureaucratic questions and details that must be covered outside of the main medical challenge: how can we diagnose, treat and bring relief to this patient with his abdominal pain?
I know this all sounds like whining and complaining. The reality is that I love the practice of medicine. I feel privileged to help solve physical problems and a few emotional and spiritual ones along the way. It still amazes me that I am allowed in to some of the deepest corners of people’s lives. There is no end to the interesting challenges and opportunities to help.
But my jealous love for the practice of medicine is the very reason why I hate to see it threatened, hassled and nearly buried by minutia, tripped up by multiplied bureaucratic hurdles, and distorted by remote organizational would-be medical practitioners. As far as I can tell, the more that government, insurance companies and other overseeing parties control your medical care, the more bloated, expensive, impersonal, and inefficient it becomes. I am confounded by how the mountains of primary care needed for our burgeoning population will be provided while at the same time medical providers are ham-strung by more time-consuming demands than I could ever mention in a brief article such as this.
We cannot truly go back in time. But if there are any avenues left that reduce the government and insurance companies’ ultimate control over your health care and over your physician’s ability to provide personal care to you, I am all for it, and will vote for it in a heartbeat. Long live the threatened entity of high quality personal medical care driven by your physician and you.
Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835