After spending a morning teaching session with our interns and residents on ambulatory block rotation, my heart aches when I think about how hard we’ve made it for them to consider choosing a life of outpatient primary care.
The supervising attending faculty in our practice are working here in this environment because we love taking care of our patients, we love primary care, and we are dedicated to teaching the next generation (and several generations back) the joys, challenges, and satisfaction of a career in primary care.
All of the attendings are eminently qualified, and could easily go into private practice somewhere, join a concierge group, churn through patients in a more profitable and comfortable fee-for-service environment. But we’ve all chosen to remain here, in the somewhat sheltered academic cocoon, with a stated goal of serving as mentors and role models for medical students, interns, residents, and fellows, heading towards a life in internal medicine.
But, compared to the life they may see over in the hospital, the life of specialists, subspecialists, and sub-subspecialists who are delivering care in a more supportive environment, how can we make it easier for them to choose this life that we all love and find so rewarding, and in ways not always tangible and certainly not always financial?
The Paperwork Blizzard
On Thursday mornings, we have dedicated time set aside to meet with our residents and interns on their ambulatory block rotation, to talk about cases, review labs, brainstorm about clinical conundrums, and generally hash things out.
Despite the loftier goal that this time has been set up to be, far too often it degrades into a plethora of paperwork, a smorgasbord of signatures, a snowstorm of sheets of paper with endless itemized details about the care of our patients that someone decided we need to pay attention to so they can help us take care of our patients.
Face-to-face forms from Medicare that testify that we saw a patient on a certain date exclusively to address the issue that they’re worried about. Home care forms itemizing all of the things that the home care agency says they’re going to be doing for our patients. Prescription refills faxed to us all day long, despite the fact that we have an electronic heath record equipped with e-prescribing. Requests for durable medical equipment for care provided by specialists who have deemed themselves above this sort of thing and told the agencies to “send it to the PCP.”
Starting out in their careers, these new doctors were fascinated with internal medicine and all it encompasses, that amazing array of diseases we get to take care of, the signs and symptoms we get to evaluate, the acute care we get to deliver, the way we get to play medical detective, the way we get to be advocates for our patients in this fractured healthcare system, the longitudinal relationships we get to develop where the patients say “that’s my doctor.”
None of them chose internal medicine so they could be paper-pushers, form signers, faxers, or scanners.
Making it More Interesting
During the hour we had together, they sheepishly shuffled through stacks of faxes, and mail they’d received from numerous outside sources, and handed them over to me for a signature as the supervising physician.
Not much learning going on here.
We tried to talk about how important many of these things were for the care of our patients, the way having a home health aide can dramatically improve the lives of our patients and let them safely function in the community.
I tried to get creative and talk about the medical issues that the subspecialists were caring for, and how this durable medical equipment was necessary for the patients to stay healthy and safe.
But it all felt a little stale, that I was forcing the issue, that there had to be more interesting things we could talk about.
Sure, at one point we got into a discussion about the risks and benefits and controversies of several screening modalities, and had an interesting back and forth about the rationale behind the timing of certain vaccines.
There were a couple of cases they’d seen earlier in the week that we got to discuss, management of some complex cases and puzzles that needed further workup, but as they left at the end of the hour I felt like they were likely going to be taking away from our time together more the fact that we were shuffling papers than taking care of patients.
Fixing the System
As I’ve said multiple times before, I recognize that this stuff needs to happen, that we want our patients to safely and without fraud get the care we think that they should have when they are away from our offices.
This is a critical part of any truly patient-centered care model, because 99.9999% of the time our patients spend is lived away from our office, away from those brief moments when we have the opportunity to take care of them.
So much of prevention and avoidance of illness and the management of chronic medical conditions takes place away from us, at home, in the community, and in the workplace, and as we build a better system to help enhance the care of our patients, we need to make sure that all these moving parts do what they need to do to help further everybody’s health.
But we must decide that this cannot come at the expense of a whole generation of young new physicians, who are going to see the life of primary care as one of paperwork, prior authorizations, battling with an electronic health record that seems created only to create billing and compliance documentation, and an overall lack of any true collaboration between those of us doing prevention and chronic disease management and the rest of the healthcare system.
I’m still not sure what many of the answers are, but part of our rebellion and revolution as we try and change this broken healthcare system has to be us standing firm and saying enough is enough, we went into this so that we could be doctors, let us do this and we will do it with all our heart and souls, and let’s find a way to make the paperwork land elsewhere.
Learning from Other Industries
When a patient goes home from the hospital, and the inpatient team creates this thing called a home care plan, why is this something that I need to sign? Who decided this? And why do I need to sign it again next month, and the month after?
Maybe just the very act of them setting this up means that it’s affirmed, that this is what we want, no one’s committing fraud here, we’re just trying to get our patients what they need.
It’s time we take this stuff at face value, and if I order durable medical equipment that my patient needs, why do I need to have a form faxed to me to sign and fax back again saying I want them to have this?
We need to learn from other businesses and industries that have figured out ways to take these mundane tasks away from those who are highly trained, incredibly dedicated, and seeking to provide actual medical care. Time for some total systems redesign.
Otherwise, the choices the next generation will make are clear, and I’m sad to say they will choose to avoid this life we’ve let become so corrupted it no longer looks like doctoring.
And that would be the shame of us all, and we will undoubtedly need generations to repair the damage we are doing.