Next in a series.
Primary care physicians (PCPs) have multiple frustrations today. The greatest frustration is “time, time, time.” From in-depth interviews with over 20 PCPs, everyone said that time or more correctly lack of time was the greatest frustration of their practice (or was previously if they now were in a practice that limited the patient number to a manageable level). Each knew that they could not give the time needed to give the level of care that they were capable of giving and that their patients deserved.
Stated somewhat differently, they said that it was very frustrating to always be focused on meeting overheads and trying to earn what they thought was a reasonable income because to do so meant less time with patients and a sense of frustration and perhaps even guilt. New practice patterns have meant not being readily available to patients, not visiting them at the hospital or ER, and no longer being the “captain of the ship.”
A geriatrician told me about a time when he needed to check his patient’s blood for possible anemia. The results came back that evening but he was engrossed in various activities and never got to it. The next morning he noticed it on his desk, saw that it was normal and continued with his rather hectic schedule. Later in the day he found an email from the patient.
“I like you and think you are a competent doctor and I know that you are very busy. But you failed [my italics] me just now by not getting back promptly to me with the results of my blood test.”
The doctor, who prided himself on his caring manner and responsiveness, was deeply troubled and touched by the message. It was an important personal wakeup call. Although it happened some years ago it is still uppermost in his mind today as he thinks about what patients really need from their doctors. They need to be able to trust.
The complexity of the health care delivery system was a common frustration refrain. In such a fragmented system, “I need to go an extra mile to communicate with my patients but there is not enough time to do it.”
Other frustrations were dealing with insurers for preauthorization of a test, procedure or referral; trying to figure out what drugs were or were not on an individual insurer’s formulary (and each has a different formulary) and in dealing with their reimbursement methodology. Some insurers are very slow to pay reimbursements which mean carrying high working capital — difficult for a small practice. One noted the amount of time required to arrange for something like home care which, if the insurer was logical, would actually prevent more expensive time in the ER, doctor’s office or nursing home. PCPs find it exceedingly frustrating to deal with non-medical people at the insurance company who deny tests or medications that the doctor feels are very much in the patient’s best interest.
A few noted that many specialists were lax in getting back to them after seeing a referred patient. Since these PCPs try to send patients only to specialists that they feel are excellent and appropriate for their patients, they become very frustrated when the specialist does not get back to them in a timely and meaningful manner. Alternatively, some specialists sent notes promptly but after the first one for a patient being seen repeatedly, the notes were obviously computer generated without any real individualization. “One neurologist sent me the same note five times over the course of six months.”
Another complained that many specialists see the PCP as the “clerk,” sending the patient to the PCP to fill out disability claim forms, etc. Of course, many specialists will retort that the PCP does not make clear the reason for the referral and is not available when they try to call back.
What is very clear in this extremely dysfunctional health care delivery system is that the primary care physicians (and most other providers as well) are very frustrated that they cannot give the level of care that they believe they were trained to do and would like to do.
Stephen C. Schimpff is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, senior advisor to Sage Growth Partners and is the author of The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You.