With the announcement out of Washington about the 2015 budget, much has been made about the apparent presence of significant support for the development of more primary care practitioners in the years ahead.
This support includes programs aimed to encourage medical students and residents to choose primary care as a profession, including loan forgiveness packages.
Response in the press has already raised issues with this, suggesting that this move would do little to encourage more trainees to opt for primary care careers, and that limitations in the number of residency training positions provides a “ceiling” that would prevent us from being able to provide enough PCPs to satisfy the needs of an aging nation and new models of patient-centered care.
For a patient-centered medical home to work, we need a highly trained, intelligent, motivated, dedicated workforce of primary care practitioners standing at the center alongside the patients, coordinating care, refining systems, trying out new ideas, and developing a system that provides the highest quality care.
But it seems that almost nothing is going to tip the balance back towards primary care in the minds of trainees, until the quality of life for primary care practitioners is also brought up to par with those of other practitioners, and the economic playing field is leveled.
Let’s take a look at my mail from this morning.
When I arrived at work early this morning, there were 42 letters in my in-basket, and 17 faxes. (Faxes? Who faxes anymore, anyway?)
The majority of these were paperwork that required my review of some information, and my signature, and really did not provide added value or care for my patients.
The bulk of these were from insurance companies and visiting nurse services, who needed to do their due diligence and make sure they had the appropriate paperwork on hand in case an auditor came looking at their files.
“Patient to be aware of signs and symptoms of their disease, patient and caregiver to be aware of risk of falls, patient to be aware of signs and symptoms of broken skin integrity, patient to be compliant with medications within 30 days, patient will be compliant with their care plan within 30 days.”
Endless, not very useful trivia, bureaucratic mumbo jumbo that my signature does not really add to, doing little to further the health of my patients.
There were a few letters from other healthcare providers, informing me of their consultations on my patients, including one from a subspecialist who actually shares my electronic health record, at my own institution.
So think about it: After he finishes his electronic note, he has a staff member who prints all of his notes, folds them, hand addresses an envelope, puts that note in the envelope, affixes postage, and mails me the consultation letter.
This seems to defeat the purpose of an electronic health record, and prevents the actual coordination of care, or at least makes it much more difficult — something that our 21st-century systems should aim to facilitate.
FYI, routing the note to me in the EHR takes one click of the mouse.
We all knew when we entered this profession that there was a lot of administrative burden that went along with it, but this has reached a point where we are all inundated — buried under an avalanche of paper and forms — and the minutia of our nonmedical lives prevents us from really providing the care and time we need to give to our patients.
We as a profession must ask ourselves, why would bright, motivated, talented, young medical students or residents choose to enter a field where they are swamped, overwhelmed, and not really practicing medicine any more?
As we move forward developing a patient-centered medical home, and as the bureaucratic and administrative landscape changes, we need to help recreate a system wherein we as practitioners are not dictated to about what we can do to take care of our patients. We have clearly let ourselves be pushed down by a system that keeps us from practicing medicine in the way we believe is best.
I would argue that the amount of money spent over the course of a year by insurance companies and visiting nurse services on paper, envelopes, personnel to print letters and stuff envelopes, and postage, could easily double the salary of quite a few primary care practitioners.
The number of employees at our own institution who are printing and mailing out consult letters could be re-tasked to roles that actually improve the care of patients, working with practitioners to provide care coordination, serve as community liaisons, and provide after-visit care.
As we all know, bureaucracy is necessary up to a point; we need to make sure fraud doesn’t occur, and there needs to be some paper trail. However, I would think that in this modern world we would be able to figure out how to make this stuff happen without taking such a lot of time from practitioners who were trained to practice medicine. I did not take a course in medical school or residency on filling out forms.
Now if you’ll excuse me, I’ve got to get to my mail.
Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home.