The primary care physician is being slowly picked to the bone

My first instinct was to yell into the phone as loudly as possible.

“Run away, run away while you still have time.”

But I suspected that the medical student on the the other side of the mobile would have been traumatized.  She was just trying to find an attending to shadow.  How was she supposed to know that at that exact moment the nursing home administrator had pulled out thousands of computer generated order sheets, each bearing my hand written signature but apparently now needed to be dated?  For ten years I had signed these documents without dating them.  But all the sudden some distant regulation had changed,  and I was on the hook.

Certainly annoying, but no big deal.  At least, no big deal unless taken in context of the rest of my day.  It started at 6am with a phone call from the nursing home announcing a skin tear.

“Sorry to wake you doc, we are following the wound care protocol, but its regulations, you know.”

Then there was the discharge from the hospital.  After seeing the patient and documenting appropriately, a new litany of paperwork: medication reconciliations, continuity of care forms, discharge instructions, and a face to face evaluation forms.

The office was no better.  The papers on my desk had stacked up over the last twenty four hours.  I plowed through the hand written narcotic scripts, assisted living history and physical forms, duplicate death certificates, FMLA forms, and disability questionnaires.  Of course, the power wheel chair application for my paraplegic patient was denied because I forgot to strike a pertinent negative from the review of systems.

All of this before seeing my first patient and contending with the futility of meaningful use and all those pointless clicks.

The primary care physician is being slowly picked to the bone.

Better to not say a word to the medical student. Let her shadow me.  The facts will speak for themselves.

Another budding radiologist, dermatologist or allergist in the making.

Jordan Grumet is an internal medicine physician and founder, CrisisMD.  He blogs at In My Humble Opinion.

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  • NewMexicoRam

    The handwriting is on the wall

  • Suzi Q 38

    “If you had the chance to do it all again…would you?”

    • buzzkillerjsmith

      I wouldn’t. As George Bush famously said, “Fool me once, shame on you. Fool me twice, won’t get fooled again.”

      You know what he meant.

    • NewMexicoRam

      No way.
      I should have stuck with design back in high school.

  • BionAlexHoward

    Sounds like the paperwork is the problem. Why don’t you hire a scribe?

    • buzzkillerjsmith


      • BionAlexHoward

        Sanity > cashflow

        • buzzkillerjsmith

          cashflow > going belly up

          • BionAlexHoward

            Maybe a better WORKFLOW is what’s needed. If doctors didn’t have so much administrative work, there’d be much more time for pure intellectual work (which creates value as opposed to paperwork, which doesn’t)

            So regardless of scribes or not, we really need to think about ways to automate as much bullshit as possible. That’ll probably be more about computers than human underlings, now that I think about it.

          • ninguem

            The mindset you just spouted, you may think it’s original but has been done long ago.

            It resulted in office visits producing three page notes, most of which is cloned.

            When I ask for records on new patients, I can get two hundred page documents from the big box clinics and HM0′s, to find less than a dozen pages of information that’s actually clinically useful.

            The reason we end up with these document dumps, by the way, is nonphysicians telling the physicians how to do their jobs.

            Both sides do it. The left and the right make insipid claims of how electronic health records will revolutionize healthcare.

            File that right up there with solving the healthcare cost crisis by “eliminating fraud and abuse”..

            ….slapping palm on forehead……why didn’t I think of that?

          • BionAlexHoward

            It’s odd to me that you guys seem so resigned to let the system suck as much as it does, and just soldier on with the status quo. I didn’t post that to be original. Originality and effectiveness are two different things. It just seems obvious that a big part of the issue is duplicated or wasted effort on trivial tasks. I say the solution to administrative overload is to try to reduce or eliminate paperwork/regulations/administration.

            If an intervention lead to 3 cloned page notes, then it wasn’t actually done in the spirit of what I’m talking about. You say “it was done long ago” as if improving our jobs and getting rid of useless waste in medicine was a one-time deal. It’s not. “Kaizen” as the Japanese call it is a permanent state of mind that we need to have. I 100% agree with you that the real key is to give nurses/doctors the power to actually change things instead of expecting top-down regulation to solve our problems. Clearly that isn’t working too well.

            EHR does not instantly or inherently mean that all problems are solved, and many seem to be under the false impression that it was going to be a silver bullet. Like any computer program, they’re buggy and annoying in early iterations. We need to streamline them a lot. We need to work on interoperability and networking and the user interface. But the point of computers is that they can potentially automate some of the bullshit and free doctors to actually doctor.

            For the 200-page dump, that sounds like an excellent job for IBM’s Watson, or other assorted NLP program: it could read the whole thing and then the doctor could just ask it questions. Or we need a standard way of transmitting structured patient data so that docs aren’t shuffling through reams of junk instead of getting what they want, which is a concise summary of H&P, good visualization of imaging + labs data records, detailed records if needed, and frictionless order entry. If the EHR was just listening to the interaction of doctor and patient and pulling out important details along the way, then the doctor wouldn’t need to waste precious time.

            Plus, how many patients come in for whole visits just to accomplish something that could have been done in 5 minutes via video chat or email?

            As for cost, it’s about incentives and feedback. No one in the room has an incentive to do less medicine right now, and no one in the room has feedback on costs when they’re deciding what to do (maybe that’s good/ethical, but it certainly doesn’t drive costs down). Chargemasters are absurd and so everyone overpays for consumables or tests. 18$ for one blood glucose strip, for instance. When you combine incentives for high volume, incentives for high prices, and a lack of price feedback, it’s not hard to see why there’s a cost problem.

            Anyway, pardon my optimism. Maybe after med school I’ll be a grizzled pessimistic naysayer myself.

          • ninguem

            More to the point, maybe after medical school, you will have learned something.

          • BionAlexHoward

            As long as I don’t learn your attitude of defeatism, I’ll be happy.

          • ninguem

            Not defeated by any means. The docs that remain in independent practice…..independent PRIMARY CARE practice no less…..are the most idealistic of all. I’ve had EHR’s pushing 20 years now. I know what they can do, and what they can’t.

            We’re not “stuck”, we just refuse to do something that is obviously making things worse.

            Unfortunately, you’re becoming part of the problem, not part of the solution.

          • ninguem

            Late 1970′s, early 1980′s, medical school, they dabbled with computer-assisted education. They gave me a soltware program with a hypothetical interactive patient.

            Anorexia, fever, periumbilical pain that migrated to RLQ…….straightforward enough.

            My answer, I entered “appendicitis”.

            I failed. the answer was “acute appendicitis”.

            The software needed work.

            I got to be part of the class-action suit over Medical Manager back in 2000, they were non-Y2K compatible, they promised a fix, lots of people believed them. They offered the fix, and charged us more than the software was worth when we first bought it.

            It was kinda cool, you’d meet these little old church ladies working in a doctor’s billing office, watch like you flicked a switch when you mentioned Medical Manager, they’d start swearing like a longshoreman.

            The software needed work.

            The Brits had a spectacular failure with their national EHR, it cost them 12 billion pounds. They scrapped it completely.

            The software needed work.

            I have no problem with using personal computers in medical applications, use them all the time, and have for nearly 30 years.

            It’s bad stuff being forced on us, by people who clearly have a vested interest in the product……that’s what we object to.

          • buzzkillerjsmith

            What ninguem said. Almost unbelievable, I know, but what you suggest has actually been thought of by those in the medical field! And their front office staff. And the back office staff. And the medical assistants. And the nurses. And guy lying on the floor drunk in the waiting room.

    • ninguem

      Are you going to pay that scribe’s salary?

  • drll

    Nothing new here. A paraplegic without the needed wheelchair, but the dates were all corrected.
    i am not sure I want to go to the next post.

  • lord acton

    There is a solution. I no longer take any insurance. My direct pay practice is 3 years old and doing great. More importantly, I am actually practicing the way I want to, not getting squeezed to death like the author describes.

    • ninguem

      That’s looking to be the solution more and more.

      • Alice Robertson

        But that’s limiting. The US only has xx amount of patients who can go that road, therefore, it’s a solution for a small percentage of doctors. Not to worry single payer is coming to a Clinic near us eventually, then only rich will use doctors who don’t take insurance payments or government payments.

        • lord acton

          I charge my patients $50 a month, most are far from rich.

          • Alice Robertson

            That’s not the full amount you are charging. For a cash only service you must be charging a subscriber fee plus the service? I pay more than that to see a doctor with insurance, but no way can the bulk of your patients pay cash only w/0 some kind of insurance for testing, etc. unless they are making some good money. The working poor simply can’t afford it.

  • Dr. Drake Ramoray

    “Better to not say a word to the medical student. Let her shadow me. The facts will speak for themselves.”
    They will see it and choose something else to do. I’d be interested to know how much debt this student is going into (not the national average but this actual student considering primary care) in order to make a career out of what bureacrats are turning into an algorithm following, meaningful use driven, scribe. We are moving so far away from patient care it’s not even funny.

  • Dike Drummond MD

    The conditions of your “job” as a doctor or in any other profession are a choice you make every day with your feet. You agree to do this job description, for this pay. You show up and do the work and cash the check.

    If you blame, justify and complain … you have chosen to play the victim instead. This victim mentality is rampant in doctors. We are really smart people when it comes to diagnosing and treating disease IN OTHER PEOPLE and really blind when it comes to seeing our own needs and acting to get them met. It is a consequence of the conditioning of our medical education.

    One of the places it comes out these days is residents voicing to their faculty advisors their wish to never become like the burned out faculty who staff their teaching program.

    What speaks for itself in this article more loudly than the mindless paperwork hassles is the attitude of the provider. If your attitude is you are being “picked to the bone” …. that is what your day will feel like. Until you

    - Change the things you have the power to change
    - Let go of the things you can’t change
    - Choose your attitude

    Now, you may need to change your job or your entire profession to get what you really want in your life. When you look back from your death bed … you will probably feel that day was a turning point for you. I very much doubt you will look back and wish you had done more blaming, justifying and complaining.

    Remember … insanity is doing the same thing over and over and expecting a different result. If you don’t like what you have … then do something about it. You have that power.

    Dike Drummond MD
    117 ways to prevent burnout in the MATRIX report

  • Alice Robertson

    Are you a type of an ACO? That’s where the money is. My doctor friend is running an ACO and his patients are mostly Medicare and he is raking in money on the government tab.

    My claim can’t be disputed when it’s cash only it’s the rich, and you obviously aren’t cash only. You can’t compare it. You are using government money and private insurer money. I am surprised you even tried to make a comparison.

    So who is it big to speak of cash only plans when you have the anonymous name of “Lord”.

  • Insider Physician

    Doctors can choose not to accept low paying insurance…. That is the problem.

    No other profession in the US has workers who can choose to demand cash.

    There is corruption in healthcare. “Old-time” physicians have limited the number of residency positions in surgery. This limits the number of practicing surgeons.

    Supply / Demand. = $$$ for doctors.

    What is a solution? Stop paying resident physicians. Congress must re-define the “payment of resident-physicians” and MANDATE that the ACGME increase positions.

    NEJM and others argue that positions could be increased if funding increased…. No no, cut payment to resident physicians by re-classifying their job similar to how a waitress makes less than minimum wage.

    The reasoning: resident physicians are STUDENTS.

    Why do you think so many foreign medical graduates want to train in the United States? It is not simply because the US is a great place, but because those at the top of the medical profession have, intentionally, over years, limited the number of residency positions to create a demand for physicians. Thus, your doctor can charge nearly whatever they like.


    1. Reclassify residency as SCHOOL & pay LESS $$$ to residents.

    2. Mandate that the ACGME INCREASE residency positions.

    3. Pay physicians LESS.

    4. Fewer rich doctors results in fewer frivilous lawsuits.

    • Shashi

      hahahaha. Are you kidding me? Pay resident physicians less? 30-40 K is LESS for the amount of hours they work. It is already next to nothing. Alright. Let me put this in perspective for you. Doctors go to school for several years before starting residency. All of those years make it extremely difficult to have any sort of a “job” or income on the side; Too many hours in school/ rotations. You want to add another 3-7 years of basically unpaid internship to that list? They are human, have families to feed and loans to pay off. What is everyones deal; picking on doctors salaries? and now RESIDENTS salaries. There are people making a shit load of money out there in various other fields, with NO ONE to question. Nope, instead pick on the poor residents. What next? Doctors should provide services for free?

      • Alice Robertson

        Quote: There are people making a shit load of money out there in various other fields, [end]

        If you go the labor statistics the top ten earners are doctors. I, personally, think a good doctor is worth his weight in gold, but the truth is it’s a fantastic field to chose if you want to earn a very good living compared to the rest.

        Forbes: The BLS (Bureau of Labor Statistics) survey reflects May 2012 salary and employment data gathered
        from more than one million businesses. Nine of the nation’s 10
        highest-paying occupations are in the medical field, including surgeons,
        internists, orthodontists, and general practitioners.

        • Shashi

          Who do you propose should be on the top of that list? A high school drop out? A waiter? They go to school the longest and are in a significant amount of debt. Think about the residents/ doctors who are starting a family, maybe married to another doctor with more loans, mortgage? How many other careers need that kind of an investment and commitment? The time doctors spend in school, other professionals have spent making an income (even at 50 K x lets say ~ 8 years). How many years is that of lost income potential + debt? I can agree that some doctors make significantly more than they should. But I could make that argument for the athletes that rake in 20 mil a year. Why are doctors always a target? These athletes have no debt, less schooling, exorbitant pay all for entertainment? Doctors are saving lives while sacrificing their own ( no social life, missed youth, missed everything really). 150 K – 300 K salary is peanuts compared to some of these athletes, politicians, celebrities etc. So america values entertainment > education? Value that when one of these hot shots drop dead on the field.

          • Alice Robertson

            I think you are so hyper sensitive you didn’t even read the intent or in context. Did you see where I said a “good” doctor is worth their weight in gold? I had one doctor who treated my daughter’s cancer and he is top of his field and bought a 2 million dollar house. Good on him….now some of his colleagues probably deserve to live in the trailer (like the one who didn’t read the lab notes twice and sent me home telling me all was well and no malignancies).

            I think doctors are fairly paid and if you have a problem with that then you need to either talk to who decides what you are paid or find a way to change the data because I have nothing to do with what you are paid. Quit frankly with all it’s problems a performance pay may in some cases be a good idea, but that grading system is highly problematic and will kill people when doctors who care more about their rating system take only the really healthy people to make sure their grading system remains high. Isn’t that what this thread is about? Status? So many doctors rant about the Ivory Towers while maintaining the same mindset. The yeah…let’s lynch a medical student because he was too preoccupied with his studies to clean up some poop on the floor. Ha! Yeah, that will make their whole image much better!:) And let’s forget about their stinky attitudes. Sorry the comparison begged to be made and I am being silly to make a point.

            The image making machine from a group that can put stockades on those who don’t conform to the supposed puritanical lifestyles we are led to believe they are portraying to the public (unrealistic portrayal).

            Quite frankly if they give every doctor a 10% pay raise today I could care less. You sacrifice a lot and I really don’t think doctor’s wages are making that big a difference in the taxpayer outlay. I think it’s big hospitals that are killing the system with what they charge insurers and the uninsured. And in most cases big hospitals will dictate your pay scale, so your beef may be best taken to those administrators not with me. Actually, I am in the doctor’s corner most days, but not when they get smug and go on witch hunts of those who don’t conform. That’s highly bothersome because an idiosyncrasy is commonplace amidst the highly intelligent and I sorta want the highly intelligent to be involved in research….because it may be that one strange doctor who finds a cure that will cure my daughter’s cancer that has spread to her lymphs because of a delay in treatment caused by an ENT at Cleveland Clinic.

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