Doctors and Do Littles

Of all the fear purveyors, the Death Panel Jerimiads, the Betsy McCoughey types trying to attract a spotlight to themselves, one of the most reliable lines is, "Do you want some government bureaucrat telling your doctor what he can do for you?"

Fact is, doctors have been told what they can and cannot do by insurance companies for decades.

Sometimes the intrusion is easy to see--as when an insurance company clerk, staring at her computer screen in Oklahoma, tells your doctor in Connecticut he cannot order an MRI or a lab test because she cannot find the reason he wants to order it on her screen. That's been going on for years.

More recently, as 88% of all doctors have moved out of solo practice and as they have become employees, they have come under scrutiny of the company. The company has to employee auditors to be sure the doctors keep records in sufficient detail to justify whatever level of visit he charges for.

The explosion of rules governing the doctor's medical record means he must spend more time satisfying the bean counters than he actually spends listening to and responding to the patient.

Usually, the doctor tries to go through the checklist before and after he steps into the room with the patient. The patient then complains, "He only spent 10 minutes with me."

Yes, that's because he spent 20 minutes going through the checklist which would make the airline pilot's pre take off checklist look like a snap. He has to verify he has acquired enough "points" for an old problem which hasn't worsened, an old problem which has worsened, a new problem which needs no work up, an new problem which requires an evaluation, that he has documented he has reviewed records from other doctors, or his own, that he has adjusted or not adjusted medications, that the problem he is addressing is life threatening or not, that there are chronic problems with implications for the patient's longevity and...well, you get the picture.

The very structure of the doctor's notes, which in medical school and in all his training reflected a logical approach to the patient's problems are now designed not by a medical school faculty or even by practicing physicians but by the auditors who review his charts who must be able to quickly assign "points" for his visit with the patient.

The rule is, "If you did'nt write it, you didn't do it."

And Heaven save the poor doctor who has billed for one level of visit without enough points: He has committed "Fraud and Abuse."

The auditor calls him on the phone and says, "Doctor, how do you look in orange?"

Meaning, of course, he is risking jail time for the grievious offense of failure to document enough points.

If the devil ever has been in the details, it is in the details of every doctor's visit.

Surgeons, consultants are less subject to this burden, although they do not escape it. But it is the primary care physicians who bear the heaviest burden. Is it any wonder so few doctors stick with primary care?

What really drives doctors wild is the relentless intrusion of non physicians into areas which the doctors know they know more than the bean counters.

A very punchy line from the 1960's is "The practice of medicine is simply too important to be left in the hands of doctors."

Everyone liked that one a lot.

Now we have reached the point where "The practice of medicine and it's costs are too important to allow the doctor to intrude."

Now, a certain amount of whining from doctors about paperwork and the loss of their perch on top of the pyramid of delivery of medical care has been with us for decades. The difference is, the doctors who complain about being thwarted by non physicians, those complainers are actually correct.

One test of whether or not to believe doctors in this country who complain about watching good medical care thwarted by non physicians is what we see in other countries. T.R. Reid, in his wonderful book comparing American healthcare in the USA with other countries, elucidates how different the practice of medicine is in Germany, France, Spain, England and Canada. And the big news is, despite all we have been told here in the States, other people in other countries are very satisfied with their systems. And the doctors who do much better for their patients in those systems do not feel as if their decisions and their training have been undone by "the system."

So we have arrived at a bad place in American medicine.

President Obama may be wrong about some things. But one thing he is dead on right about is the unsustainability of the current American medical system. You may be one of the 70% of Americans who is satisfied with your insurance plan and with your doctor.

Believe me, you are living in a fool's paradise.

You won't be satisfied for long.

Just remember when those voices in the wilderness were warning about the housing bubble and about unsecured mortgages.

Sometimes you have to know when to listen to the warnings.