When I first started in practice in the early 1990s, I shared an office with a great internist who decided to retire early and move to Europe. Both of us were doctor and writers, but he claimed that the golden days of medical practice were nearing an end and he wanted to get out while the going was still good and write full time. At the time, I didn’t believe him. Medicare reimbursements were genuinely fair and many patients with private insurance still paid us up front and sought reimbursement from their insurance after the fact. This felt right, not because I wanted my sick patients to have to spend their time arguing for payment for a service they needed, but because I didn’t feel I should have to beg for payment for a service I’d already delivered. What also felt right was handwritten patient chart notes. I realized that, like many doctors, my handwriting was chicken scratch, but it felt more intimate and patient-centric that way and it also kept me from having to rewrite every detail each time. Computerization was looming and I could see it would help with communication between physicians and hospitals, provided that privacy could be preserved on the patient side and efficiency on the doctor’s side. There was also plenty of time for me to do my writing before and after hours, in between patients, or pulled over to the side of the road the way Dr. William Carlos Williams used to do when an inspiration hit him. But then things changed. First there were the HMOS in the 1990s, which promised more but paid us less, after our service had already been delivered. Medicare cut its reimbursement rates and private insurers followed suit. Then Obamacare came in in 20010, offering a higher deductible high premium lower quality insurance, putting more pressure on me to deliver the same quality product with fewer choices in terms of doctors and hospitals. When a patient hasn’t met their deductible, it is often difficult for me to convince them to pay for a test or treatment I know they need. At around the same time, it became mandatory for me to transition to electronic health records or pay a penalty. I was compelled to learn a new system of record-keeping while at the same time keeping up with insurance and government mandates. Also around this time, medical technology began to erupt and become more personalized, esp. in the areas of genetics, immunotherapy and robotics. Treatments were becoming more effective all the time and we soon had more options than ever before, but helping patients navigate among all these options took more and more time. Despite the need to spend more time with my patients, insurance is reimbursing for shorter visits, while the amount of time I spend documenting has increased. This is far from ideal. In fact, a recent study showed that family doctors spend almost an hour and a half of “pajama-time” nightly on documentation. This leads directly to physician burnout. According to a 2017 National Academy of Medicine paper, more than half of U.S. physicians are experiencing substantial symptoms of burnout including emotional exhaustion, depersonalization and a low sense of personal accomplishment. Plus, by many estimates there are more patients to see but fewer physicians to see them. The latest Association of American Medical Colleges report predicts a shortage of up to 120,000 physicians by 2030. Something needs to be done to improve quality of life for physicians. I still don’t believe my friend was right to retire. In terms of my own personal yardstick, I am still able to write and practice medicine at the same time. Being allowed into a patient’s inner life and having that patient rely on my skills to help them is still a privilege and still extremely gratifying. So is practicing medicine at a time when we have so much more technology to offer our patients than before. But the next round of regulatory changes in medicine needs to consider how to make things easier for doctors, which will then — by direct extension — make things easier for our patients. Source
