Early in my medical training I envisioned myself as an old-fashioned family doctor. Marcus Welby, MD was well before my time, but he seemed like a good fictional role model for a naive student-doctor. (Especially considering Dr. Cox of Scrubs was my alternate choice.) After finishing my primary classroom studies, I was eager to leave the stacks of paper behind and to learn from real clinicians caring for real people. After donning my short white coat (sans leisure suit), I quickly realized my romanticized vision didn’t mesh with my new reality.
As I advanced through medical school and into my family medicine residency, I was increasingly exposed to the “inner workings” of health care. Behind the scenes I saw much of the doctors’ time spent on issues other than patients’ health. Seemingly, the documentation about what they did took more time that what they actually did. My mentors frequently vented behind a mountain of charts about the decline of their profession. (Maybe the TV show just failed to show Dr. Welby filling out 5 pages of paperwork after he treated a simple sprained ankle?)
Hospital and clinic staffs consisted of small armies of people to do coding, billing, following up on denied claims, prior-authorizations and on and on. To financially support this administrative structure, the doctor(s) would take on more patients. The average primary care physician is now responsible for 2500-3500 people! I was frequently told “efficient” doctors could handle double and triple booked schedules – and it would be required to keep a private practice afloat. Unfortunately, this efficient pace allowed very little time to answer patient questions, educate about chronic diseases, calm somebody’s fears or listen to a patient’s bad joke.
During my training patients would frequently tell me about frustrations with their health care experience. While most people personally liked their physician, many felt disconnected and fed-up with the complexities of basic communication. After hearing the same stories again and again, I started to feel sympathetic towards these complaints. Despite our hard work and good intentions, medical practices often treated patients merely as vessels for billing codes. Doctors seemed to be unwittingly insulating themselves from the very people whom they committed to providing care. And this sympathy was directed towards the fortunate insured people with so-called ‘access’.
Don’t get me wrong, I met numerous amazing, compassionate physicians whom cared deeply for their patients. From my perspective, the doctors and patients were both losing in this system. I increasingly asked my colleagues, “Why do we do it this way?”, “Wouldn’t it be more efficient if ….” and other annoying questions. Usually my inquiries were met with puzzling stares and flippant answers such as, “Because this is just the way it’s done.” Despite everyone agreeing that the system “sucked”, all parties seemed miserably complacent.
Sure, many doctors were passionate about “reform” and had wide-ranging opinions about political fixes to our problems. I was encouraged to join (give money to) organizations, write representatives, march in the street, wish on birthday candles, etc., etc. But why should anyone be hopeful that such advocacy will be productive? Over the past 40 years, our country’s health care has been reformed by numerous rounds of bureaucratic acronyms -only to have theGordian knot become increasingly tangled. A perpetual Groundhog Day was not my idea of a fulfilling career.
I remain skeptical about any topdown solutions to our conundrum. I am not waiting for another round of regulatory tweaking to improve the value, access and quality of my professional services. We all deserve better, but we are not going to get it without some disruptive innovation from the grassroots. I believe doctors and patients can and should return to a direct, cooperative relationship for most health care issues. Maybe physicians never have been the caricatures from the golden days of television, but I’m happily and stubbornly naive. Something has been lost and we should fight to get it back again.