Time is of the essence. The very utterance of this phrase connotates a sense of urgency for an impending crisis or adversity if some essential action is not taken. I find myself most unexpectedly at this crucial junction. I am a seasoned, experienced general internal medicine physician, trained traditionally in hospital medicine, and subsequently evolved into outpatient care of comorbid complex chronic disease management. From everything I read and hear about, I should be one of the most sought physicians to meet today’s patient population needs. But our current broken health care system fails to respect and accommodate the requirements necessary to succeed in managing these challenging patients, and the reality today is that I am marginalized and diminished in capacity by forces removed from my influence.
The two most important stakeholders critical to successful outcomes in the provision of health care are the patient foremost, and the health provider secondarily. A bonding of trust and understanding is required to achieve any semblance of a constructive working relationship for mutually agreed-upon goals. Time allowance to properly diagnose, educate, and effectively “sell” a diagnosis and treatment plan to a patient is essential. Any erosion of these cornerstones of care, and failure to achieve an optimal outcome is guaranteed.
As a patient, we desire an unbiased, knowledgeable, compassionate provider who understands our unique circumstance, and the challenges facing our lives, who devotes the necessary time to accurately achieve this goal. I am convinced most providers strive to become such a health care professional. However, the obvious fallacy of limiting the time available to cultivate such a relationship undermines the capability of establishing this therapeutic encounter. The consequences are predictable; an unsatisfied disgruntled questioning patient, a disheartened anxious provider struggling with diminished confidence in decision making, and an assurance of non-adherence to therapeutic planning. From this core dysfunction stems a dizzying array of mismanagement, centered on thoughtless irrational testing, overprescribing unnecessary or harmful medications, and the initiation of a cascade of avoidable complications inherent with such error-filled action. Additionally, many providers simply shut down and kick the can down the road, referring time-consuming patients to multiple subspecialists, each who has less inclination to manage the patient from a larger holistic perspective necessary to achieve success. The extreme fractionated care that results exacerbates this core dysfunction, and diminishes the quality of care, jeopardizing positive outcomes. Sadly, this dystopian system characterizes America’s broken primary care today.
When the power to dictate how much time a provider spends with a patient is divorced from the primary participants, an unrealistic expectation and demand upon the involved parties occurs, while the nonclinical administrator remains insulated from the destructive consequence of that decision. Where is the logic in having a person who has never had to perform the actual work dictate how much time one should take to perform the job? Is this a formula for success? Years of neglect in appropriate reimbursement for cognitive outpatient care, with ever-expanding unfunded mandates that raise overhead expense, has resulted in the progressive decline in access to primary care physicians, and the explosion of lesser trained physician “extenders” substituting for them. The power imbalance between administrators and providers is further widened by this dynamic. This dysfunctional relationship is at the heart of our failing health care system across America today.
Reflecting upon three decades as a primary care general internal medicine physician, I am at a crossroads in my career. While peaking with knowledge, experience, wisdom, and skill, I am unable to find an employed practice setting (solo practice became financially nonviable over a decade ago) that accommodates the requirements necessary to effectively provide for our most time consuming, complex chronic disease patients. Yet, this skill is precisely what is needed most with our aging population, and increasingly rare to find. With costly chronic disease management, there is little room for half measures and short cuts that today’s health care systems demand. My time is diverted from medical decision making and consumed by the crushing weight of administrative paperwork buried within cumbersome electronic medical records created to satisfy billing demands, ensuring the impossibility of finding a legitimate work-life balance to create professional contentment. This burden is uniquely and disproportionately borne by the primary care physician. For over a decade now, I read and hear that relief is on the way, but nothing truly changes, and I see no reason to believe the future holds otherwise. The progressive decline in the number of primary care physicians is foretelling.
Am I being forced into a premature “retirement” from medical practice because the only financially viable practice options today come at an unacceptable cost to the patient and the provider? The uninformed may choose to call this “burnout,” indicting me as a weak, inadequate physician, when more accurately, it is simply a choice to end participation in an irrational, constrained, inflexible, dysfunctional system. It is abundantly clear that I am not alone among my peer colleagues in grappling with this dilemma today.
Is it too late to right the ship? Where will the solution come from? Are we about to permanently lose precisely what we need the most? Will we ever understand that time is of the essence?
Ross L. Fisher is an internal medicine physician.
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