Practice hassles are threatening our profession

Do you know anyone who has tried to find an internist recently? Good luck. Internists are either overflowing with patients, switching to retainer medicine, switching to hospital medicine or quitting. Internists are frustrated, burned out, and unhappy with the external transformation of our wonderful profession.

We spend 20 years in school, and then 3 years of residency training. We learned to think and apply our cognitive expertise to the diagnosis and treatment of our patients. We did not choose our profession to rush through appointments, author uninformative notes or use EMRs that create unreadable notes. We did not choose our profession to solely tinker with medications for diabetes, hyperlipidemia and hypertension. We went through training to first make a proper diagnosis, and then to individualize a treatment regimen that takes into consideration the patient’s multiple diagnoses, their personal desires and goals, and their socioeconomic situation.

Fee for service has transformed internal medicine in undesirable ways. We worry about RVUs, productivity, and do our best to streamline patient visits. We do not have time to properly investigate the patient’s complaints, or to have important conversations about preferences. No one pays us to do the right thing (or at least how I define the right thing).

Practice hassles are threatening our profession. They got me 15 years ago. I switched to solely teaching inpatient medicine. 2013 inpatient medicine has a better chance of matching the Oslerian ideal than does outpatient medicine. And yet inpatient medicine has many of the same challenges as outpatient medicine.

And who really suffers? The patients too often receive less than our best effort. We hurry between patients, short change the time spent with patients, and stare too long at computer screens. Patients want, and need our attention. They need us to have conversations not brief question and answer sessions. They need us to understand them and treat the patient who has the disease.

Unless we can change the various hassles that current rules impose on billing and EMRs, outpatient internal medicine will continue to die a slow death. Patients need excellent internists who enjoy their profession and love caring for patients. We must extinguish the concept of RVUs and meaningful use. We must return to the principles of good patient care defined by Osler, Tumulty, Harrison and the other giants of clinical internal medicine.

But is anyone listening?

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • kjindal

    no. nobody is listening. except for other commiserators (us).

  • Suzi Q 38

    Unfortunately, the doctors are too stressed out and tied to care anymore.
    The patients are angry about that, but powerless to do anything.

  • buzzkillerjsmith

    Hassles. We might not have seen nothin’ yet.

    Just a few minutes ago I read or skimmed a bunch of articles in an Ann Fam Med supplement on the PCMH. Take homes: No convincing evidence of meaningful quality improvements, unknown effects on the financial implications for practices, possible worsening of morale with more night and weekend work, it’s important to have “leaders” in practices to transition to PCMHs. ( Of course it is, and it is necessary that the “leaders” be able to intimidate or fire people who don’t go along, because only an idiot would willingly go over the cliff with the other lemmings.)

    Conclusion from the editorialists: Change in mandatory, no optional.

    I’ve said it before and I’ll say it again. If you are a med student and you go into primary care, then you are a fool.

    • LastoftheZucchiniFlowers

      buzzkill – worse than this, the EMR has failed to improve ANYTHING in the public health. It has organized information and made clerical record keeping more efficient, that is all. We now actually due MORE clicking than ever, just to refill an rx. I checked today and it took TWENTY clicks just to complete that simple task. Now, multiply THAT by hundreds of refills (and my nurse/med asst can’t do it form me!) Doc only access!

      • buzzkillerjsmith

        That’s nuts. If you don’t mind me asking, what system to you have?

      • Dr. Drake Ramoray

        You left out that healthcare will get more expensive with EMR’s (the opposite of what it was supposed to do) because its easier to get your documentation right and bill for a higher level of service. Doctors will stop under billing Medicare.

        Something sponsored by the government making things more inefficient and more expensive. Boggles the mind. /s

    • southerndoc1

      As the authors of one article in the supplement conclude:

      “In the presence of a vision for transformation, operational leaders within practices can facilitate practice changes that are associated with clinical improvement.”
      Love it!

      • buzzkillerjsmith

        Yeah, and if you believe that, here’s another one: “In the presence of a vision for transformation, operational leaders within alchemy can facilitate changes that are associated with turning lead to gold.”

        • southerndoc1

          “In the presence of a vision for transformation, operational leaders within the AAFP can facilitate professional changes that are associated with turning dedicated, creative physicians into exhausted, burnt-out mid-level managers.”

      • _userM9801

        “In the presence of a vision for transformation, operational leaders within practices can facilitate practice changes that are associated with clinical improvement.”

        I have a friend who used to collect gems like that, format them prettily, and feature them on her website under the category “Mission Statement Hell”.

    • LeoHolmMD

      It’s going to be a sad day when the evidence catches up to the PCMH. Insurance companies/Medicare are not going to increase funding to the point that will pay for the massive investment. All these PCPs are going to be hung with the expense of setting up a system that doesn’t work and is unsustainable. The PCMH is not being chosen, it’s being forced. I hope all the people who came up with it are still around when it crashes. You can bet they won’t be held accountable.

  • LastoftheZucchiniFlowers

    This is when things will get better: when doctors once again become their own bosses (instead of the hospital/HCO). Then, the PATIENTS (not the insurance companies) can become the doctor’s ‘customers’ and informed CONSUMERS of health care services instead of beneficiaries of some 3rd party payer. Until this massive paradigm shift takes place – nothing will get better. BUT – the SCIENCE and the delivery of medicine will get smarter, faster more portable to the masses via smartphones, genomics and Watson. Yup. I’m a disciple of Dr. Eric Topol – but WHO IS GOING TO PAY? Not I, said the Duck.

  • Anthony D

    No. The problem with PPACA
    (ObamaCare’s real acronym) is that is fails completely to understand
    the real problem or deal with it. The primary reason that medical
    prices have been growing faster than inflation for many decades in a row
    without end is because of Third Party Payment. TPP break the market’s
    natural cost control mechanism…which is prices being paid by the
    consumer.

    In a HEALTHY market, a consumer pays for goods and services and
    therefore has incentive to seek the best total value he can. he
    prioritizes from himself what is important, and what is worthwhile. The
    provider is always under pressure because of this to innvoate, be
    efficient and meet the consumer’s expectations and desires at a price
    point that both can live with.

    But in the medical market in America, the consumer doesn’t pay. About
    90% of all medical dollars are spent by someone OTHER than the patient
    (insurer or government usually). But wait, it’s worse! because not
    only do most people not pay for 90% of their bill themselves, but their
    insurance isn’t even paid for by them directly. Either their employer
    or the taxpayer pays. So you really have 4th party payment MOST OF THE
    TIME.

    The effects of this are a classic Moral Hazard (if you don’t know what
    that is, look it up, it’s an important economics term that every
    American should know). The consumer, because he doesn’t pay for
    anything, is incentivized to overconsume medical services. The
    provider, because the consumer doesn’t worry about costs, is
    incentivized to overprovide.

    Thus unnecessary tests are prescribed, unnecessary procedures, new
    expensive drugs are prescribed when an older cheaper one could solve the
    problem almost as well., etc. This overconsumption is an increase in
    demand. If you know ANYTHING about economics you know that when demand
    rises, prices rise.

    In a normal market, when prices rise, suppliers have incentive to
    increase supply to capture profit which then brings prices down.
    However, medical markets have two problems. One is that training
    doctors is REALLY hard and expensive. Only so many people have the
    capacity to be doctors and it takes more than a decade of schooling and
    interning to make more, not to mention hundreds of thousands in debt.
    This is a naturally inelastic supply (another economics term you should
    know).

    But in addition to natural inelasticity, our licensing system has turned the AMA
    into a medieval guild that suppresses competition. The AMA takes steps
    to ensure that only a small number of medical colleges exist, and that
    those colleges keep from expanding their production of new doctors. The
    AMA has this power because it writes the licensing rules to restrict
    doctors to having come from AMA approved medical schools rather than
    using skills tests. The result is to give the AMA the power to control
    the supply. And no such group will ever voluntarily expand competition
    so as to lower their own compensation. So we have natural and
    artificial limits on supply.

    These are the challenges. PPACA does NOTHING to reduce them. It does a
    GREAT DEAL to make Third Party Payment worse. Independent industry
    analysts are predicting 33-169% premium rises over the next few years
    after PPACA comes online. These are not conservative interest groups.
    These are group paid by businesses to give them the most accurate
    forecasts they can so that businesses can plan for the future. They
    have every incentive to be as accurate as they can without political
    bias because the degree to which they are right determines if they get
    their next contract.

    PPACA is going to to substantial damage to our health industry. Ten
    years from now, I GUARANTEE, the situation will be SO much worse than
    today, and I also guarantee that no one on the left will admit that
    PPACA made it worse. They will instead call for more solutions that
    fail to recognize the problem.

  • Mengles

    Don’t worry the ABIM leadership is here to the rescue to make things better.

  • andymc12342003

    “I hope all the people who came up with it are still around when it crashes. You can bet they won’t be held accountable.”

    Of course they won’t. They will just heap more guilt and burdens on the busy primary care docs- tell us we need to work on our communication, positive attitude, efficiency within the PCMH, quit being so doctor centric, more patient centric, etc…

  • Anthony D

    The trifecta of technology, lack of tort reform, and disconnection of market forces from services rendered, that is the series of issues that are killing healthcare costs.

    Technology is great, life saving, life extending. We demand it as Americans and consumers.

    Tort reform is unlikely with a Congress full of lawyers. They do not
    live in the real world and cannot understand the consequences of their
    inaction. Defensive medicine is the DIRECT result (As simple as “Do I
    order this test or not? What would a lawyer ask, if the worst happened?
    OK, I ORDER THE TEST).

    Costs increase.

    Disconnection of prices from services : Medicare
    / medicaid cut the corners by creating DRG’s and bundling prices,
    having everything related to the RVU, and having a formula. Insurers
    follow to their own advantage by paying based on a percentage of
    medicare, and market forces DO work there to a small extent. Consumers
    have little or no input.

    • bill10526

      Anthony D’ comment is correct in what he says, but there is another point that I would add to it..

      Malpractice litigation is a game where clever plaintiffs’ lawyers, like stock market analysts, come up with explanations for outcomes that already occurred. The market went down because Ben Bernanke burped. The same explanations applies to a market going up.

      The logic for malpractice litigation includes the idea that the plaintiffs lawyer’s explanations are valid, and the extra tests are warranted. The lawyers save lives in the dyslectic litigation world.

      Judges and courts deal with particular cases and are limited in their ability to police themselves, although the Daulbert decision helped a lot. The legislation has an obligation to shut down malpractice as it causes overwhelmingly more harm than good. It should be replaced by some adverse outcome insurance mechanism where patients themselves pay premiums. That would tie patients to costs as well as to benefits.

  • disqus_qJEMXTKtR1

    Our medical profession has been taken over by business people while we have stood by and allowed it to happen. As lobby-controlled government tries to “re-invent the wheel” of healthcare so enhanced profit for insurance companies/HMOs/hospitals/etc. soars, physicians should look at doctors in countries that have better patient care outcomes than we in the U.S.

    Profit is the great motivator, and while politicians and special interest lawyers make complicated laws designed to confuse the populace, physicians suffer in their practice with overwhelming paperwork hassles keeping us from caring for our patients. As we become more inept at our function, business will say we can’t handle it gaining more control over our profession.

    It is their game plan. We must stop ignoring it!

    Gene Uzawa Dorio, M.D.