We can’t be all things to everyone.
It never ceases to amaze me how much “care, but no care” I see from patients who come in with chronic skin conditions. They’ve been to 3-7 “doctors”–in reality, 3-7 nursing assistants or nurse practitioners supposedly working under the wing of a physician–this is never the case. They can’t tell me if they saw a GP or a specialist! They’re confused and they can’t tell me what they have been told, diagnosed with, much less prescribed.
They certainly been asked about their flu shot, tetanus shot, seat belt, guns in the home, sunscreen usage, etc. even if they seek care for a bad case of psoriasis. Often in the course of these nonsensical interrogations, the core issue they came in for treatment falls by the wayside. They have very extensive and severe dermatological conditions which require thorough evaluations and work-ups. I request medical records. Sometimes I get them. Nobody is in charge of records anymore, they’re supposed to be “easy and seamless to access and coordinate care”. Newsflash, they’re abysmal, circa 1991 FORTRAN type in look and feel. More often than not, I don’t get records from other offices. One office even hand wrote on the fax request “Our files are in storage since we had paper charts when we saw Patient X. Do you really need the records?” Truth from the trenches!
I have to start from scratch. It’s easy to “start” because literally, nothing has been done. Patients look at me with eyes wide as saucers when I tell them I’m going to need to take a skin biopsy. I think they imagine a sledgehammer or cleaver behind the closet door to take the skin biopsy, and they simply don’t know what I’m talking about, so I talk talk talk and try to educate.
I love what I do, but I’m wondering why so much gets punted and simply isn’t done. These patients aren’t refusing medical care, in fact, they’re shopping around from store to store, looking to see who will help them. They’re being spun around like a kid at a party playing pin the tail on the donkey (is that even played anymore?).
Why, and how, is this happening? My assessment: it’s not health care, or medical care, any longer. It’s patch and turf, get the data into the EHR, collect the MIPS/MU/EHR/PQRS bonus. Punch the clock. Kick the can down the street. I’m tired and I want to go home.
This is deeply concerning and destructive. Doctors are quitting medicine altogether in droves. With no representation and no power “at the stakeholders’ table”, it has been widely documented that doctors nearing retirement have accelerated the phase-out process, and increasingly doctors in their prime are quitting medicine altogether. The AMA has long stopped representing physicians. It is a bewildering anachronism with a core mission to “improve the health of the Nation”–a big mission, nothing is mentioned about protecting the doctor. Most physician representative or “advocacy” groups are simply in business to sell products to the physicians to tighten the ropes of bondage– coding books (and videos and online courses–many updates every month it seems!) compliance manuals, maybe CME courses. I believe they are afraid to address the fundamental seismic shifts–loss of autonomy and the loss of medical practice. I don’t know where the fear comes from. Fear of change? Fear of repercussions?
As many doctors are overbooked, overloaded or simply tending to the details, and because nature abhors a vacuum, the bureaucrats have swept in to take control of the ship. I know of many doctors who have quit brilliant and lucrative medical careers to start yoga studios, vegan food services, medi-spas, health coach services, personal training businesses. This is all well and good, it’s your life, do what you want. But all of that training and hoop-jumping through med school, residency, boards, etc. flew out the window when their lives became pressure cookers. Doctors are smart self-starters. They get deluged with EHR mandates, ICD 10, ACO administrators with clipboards tallying the counts on the PQRS measure–all for the endless documentation fecal material machine–and they work harder. The treadmill gets cranked up and they run faster. For a time. They eventually burn out and are hanging on by their fingernails. For these burnt-out doctors, money isn’t the issue. It’s about ownership of their lives, and the one thing they will never get back: TIME. So they quit medicine forever and look for personal satisfaction elsewhere. The tunnel narrowed and for these doctors, time to jump ship for sheer survival.
The latest, most dangerous systems health care game: give out lollipops and please the patient above all else so they give the clinic/hospital/staff 5 stars on customer care surveys (sick patients aren’t customers but that’s a whole other blog post). This includes the handing out of narcotics, to keep the masses comfortably numb and more apt to give a favorable online review. This is happening.
Medicine isn’t like flying a plane. This isn’t an automobile assembly line. This isn’t an ATM transaction (although many would beg to differ). This is down and dirty, elbows-up-to-the-guts REAL LIFE. We witness birth and death, pain, infections, cancers. We see broken bones and broken hearts. Every human ailment, whether physical, mental, genetic, environmental and we are there. Populations don’t get sick. Individuals get sick, and we humans are as infinitely different and crafted as stars in the universe. We have free will. We can choose to take the pill, or not. To smoke, or not. And so doctors or clinics cannot be blamed and penalized when the smoker gets readmitted for pneumonia while smoking 2 packs per day. Or the sunburned skin cancer patient who applied sunscreen only to their arms. Are clinic staff to go home with the patient, following them around like a nanny, cutting off the cigarettes with scissors or chasing after them with a bottle of sunscreen spray? Only 25% of ACO’s have turned a bonus. That means 75% haven’t earned a penny in “incentives for coordinating and streamlining duplicative care and producing efficient quality care”. I suspect what’s actually happening is a lot of hand waving and boxes being clicked, but no substantive results on anything. Florida Medical Association put together a concise article with startling statistics. Read more here.
This doctor-shopping from patients, and hoop jumping by doctors, qualifies as a giant waste of energy and time. Doctors must stop being compliant and obedient– and set limits–summoning the will to be DOCTORS again instead of allowing the work place full of ancillary health staff to dominate markets, and thereby destroying medical care in our nation. Patients need to keep yelling and keep the pressure on the systems that have failed them. They must demand health insurance that works for them, not the one-size-fits-most abomination we we’ve been force fed, where single males have maternity and OB-GYN services “covered”. Or women get prostate prevention for “free”. We have zoomed down the rabbit hole…but we had to pass it first to find out what magic was in it.
We must summon the courage to say NO to the following: I will not click the box; I will not see 78 patients in 8 hours; I will not work for free. I will not do pharmacy preauthorizations, “iPledge”, or other online data entry, “in between patients”. There is no “in between” patients. It’s called owning our TIME. We must start saying no and we must start pushing back by saying YES to delivering our medical expertise and care to our patients who need us.
Many doctors have left the building. I’m just afraid that when it comes time for ME to have medical care, I will be turfed to a system that punches the card and clicks the box, in and out.
Photo by Onio-n