Old school doctors like me used to give the vast majority of our time and attention to our patients. Our documentation took very little time and our support staff sorted all incoming data – lab results, x-rays, consults and hospital reports. They would prioritize things for us: courtesy copies to just sign, tests we ordered that came back normal, our tests with abnormal results and so on.
In the new world order, doctors and other medical providers are the first ones to see incoming information. It arrives in our inboxes throughout the day and night, and then it is up to us to sort and delegate everything.
This is something we are never scheduled protected time for – we are supposed to do it “between patients”. What that means is that, in order for us to stay on time, no patient visit should ever be as long as it says in our schedule – since we’re expected to do all this important work “between patients”.
I have to admit this has been hard for me to swallow and adjust to. One reason is all the health maintenance and preventive medicine we are required to pay attention to, even though as I keep saying and writing to no avail, that isn’t usually something that requires a medical degree. The other reason, of course, is that if you ever hope to get people to follow or at least consider your medical advice, you need to have a relationship with them, and that takes a little time. You can’t treat people like cattle in a roundup and expect them to follow your suggestions and prescriptions.
I work hard at delivering technically good care. I put effort into my personal relationships with patients. I don’t mind that.
I keep falling behind in monitoring my 23(!) different inboxes. I think there are too many of them and I think much of what’s in there shouldn’t even be coming my way. It’s just a liability trap, designed to make sure that if anything goes wrong, the blame will land squarely upon us.
So how do I tell my patients I’ll be shaving some more time off what they think is the contracted amount of time they have come to expect with me?
We desperately need to reimagine the primary care visit and the primary care flow of information. Bottlenecking equals burnout.
A Country Doctor Writes: 
You seem to be a gentleman, hard working, a caring doctor, up to date, and very smart. As I read your note today, I am starting my 5th year of retirement from family medicine after a 40 year career (including 3 years in residency). I am celebrating this occasion by spending a month in St. Croix, U.S.V.I. It is 80°, I am relaxing by the pool reading, and patient care and responsibility are not even in my most remote thoughts. I am 69 years old and loving my new life. Best wishes, Doctor!
I’m 69 1/2, it was below 0 this morning so I kept the horses in until 9. I drove 34 minutes to clean my paper inboxes at my clinic on the Canadian border. Snow forecast for tonight…
This is so true. Failed faxes come to me first. Some admin issues too. Patient concerns over minimally abnormal lab parameters that they see in the portal. The rapid fire of all of this is undoable
YOU ARE SO RIGHT. EVERY TIME THEY CHANGE MY PRIMARY DOCTOR I REALIZE HOW GOOD THINGS WERE IN BUCKSPORT, I HAVE HAD AT LEAST FIVE PRIMARY DOCTORS IN THE LAST TWO YEARS. I COULDN’T EVEN REMEMBER THEIR NAMES OR WHAT THEY LOOKED LIKE.
I SURE REMEMBER THE TIME YOU WERE MY DOCTOR. I WAS SORRY WHEN YOU LEFT. I HAVEN’T WRITTEN A POEM SINCE TO GIVE TO A DOCTOR, NOR BAKED
BANANA BREAD.
KEEP TELLING THE WORLD WHAT IS WRONG WITH THE SYSTEM. YOU KNOW, I FEEL THE REPERCUSSIONS.
I WAS ONE OF YOUR HEALTHIEST PATIENTS, I MADE THE GRADE UNTIL I WAS 89, AND AFTER THE COVID SHOT I HAVE GONE DOWNHILL. SINCE LAST MAY AND CONTRACTING COVID A MONTH AFTER.
I READ ALL YOUR POSTS AND LOOK FORWARD TO THE NEXT. THANK YOU FOR SPEAKING OUT. I CONSIDER YOU ONE OF THE BRAVE. THANK YOU, LYNNE FINDLAY
My burn outs have burned out.
😂😂😂😂 well said
Telling it like it is! Your fellow PCP’s in practice a few decades agree wholeheartedly
150% agree. i’ll never regret the amazing relationships over 25 years nor the late notice of not finishing a chart or signing documents! Health care is meant to be the good old days way – about the health of the person in front of you! Part time now has given me the joy without the hassle and becoming a business leader in prevention and lifestyle medicine sealed the deal that the future of our children and grandchildren should not be left in the hands of the currently stressed out, admin directed physicians.
EXACTLY, at this rate there will be no one left except inexperienced newly graduated NP’s in Primary Care Medicine.
I agrée wholeheartedly with the author of this article. The EHR and electronic data monitoring did not improve even a bit the quality of the healthcare.It is designed to better control the system for the benefit of the insurance companies, hospitals administration’s profits and the large health care outfits .
The physician ability to care for his/her patients was greatly diminished.
I absolutely agree! Medicine should be about people and relationships primarily, but it’s been turned into another “industry” complete with industrial management philosophies. Patients are not cattle (as you say) or cars on an assembly line- one plan doesn’t work for all, and if they don’t trust you, they aren’t going to follow your plan! Patients want personal medicine, but insurance companies want volume above all else, and the insurance companies are the customer, not the patients…..
The sooner that you realize that the Industrial Healthcare System is based apon fungible assets the better you will feel about this whole mess. I finally began to understand about fungibles. Every “provider “ is an inter changeable cog in the System. Every patient is the other cog in the System. In other words every one can be replaced without trouble.
The problem is that Doctors became Doctors because we wanted to care about people, to ease their burdens, lead patients to better health. Every patient wants to have the idealized version of the true 21st century doctor and the care is received is top notch. We are all deluded.
Very informative.Icertainly agree with this Dr,s remarks .we have lost many practicing Dr,s to the pressures of keeping records and not being able to spend time with their patients
Ditto.
And so I retired earlier than anticipated.
And, please, as a burn out myself, commentors should stop posting responses touting mindfulness as the fix! It’s been debunked. I tried it back when it was being pushed as the fix to our troubles and it just made things worse. Taking 5 minutes to smell the roses in another wise over busy day just puts you 5 more minutes behind and more frustrated. And any momentary zen you achieved made you wonder why you were even still working at all. There’s a great story in the NY Times about this. The only thing that works is taking control of your schedule and setting limits. Have those conversations with your partners discussing the things we were always too proud to talk about. That conversation could save your life and career. As another NY Times story discusses, burnout may be more a function of isolation than workload.
It’s a shame but as stated above the “new form of care” is to hang doctors with all the liabilities, while insurance companies get their information using the doctor as a secretary for down loading and passing information on to patients. It’s very efficient for the insurance companies and highly inefficient in how time is utilized to care for patients. Meanwhile administrators are given or taking more decision making from the doctors.
Who looses? Patients loose a person who would potentially be their advocate. Patients loose their doctor relationship which once was a time honored relationship. Now that relationship is a relic of the past engineered by the insurance companies to assure their payments are maximized and administrators that enjoy being in charge, to dictate to doctors how they want “things” done and taking the doctor salaries with it. This is the new medical protocol. How it use to be is no longer and insurance companies and administrators will not permit the old way to practice to seep back into the system.
Patients are no longer important in the scheme of medical care.
You need to get with the new world order in medicine. The patient is not important. Good EMR and maximum RVUs are what matters. Hire several NPs and PAs that are less trained to make your practice profitable. Refuse to work anymore than 9 to 5 and no night call or weekends. Remember, the patient is not the center of you practice.
I have also been writing. Also to no avail. I was pleased to find Dr D’s blog as few docs speak up .I work one day a week now . I am in MAine also taking care of the left behind discouraged and disabled and I do MAT which is cool as they recover and get their kids back and get a job!
Docs need to join together and speak and then take action -we never do . I could go on . I never made much money so St Croix for a winter is out:) I was in the Ideal Medical Practices project adopting EMR early -that was a great simple tool- I saw every patient the day they called and on time. Til regulations and hospital policies killed me . I guess i was not sturdy:) Lets talk about how to speak up as one.
After 36 years of private practice as a urologist, I’m now “two day a week no call no surgery part time” and an incredible weight has been lifted. I share your concern and frustration. But I’m happy to leave it behind.
EMR is a two edged sword with incredible productivity loss and no interconnectivity benefit. Patient access to results via “portals” is like dropping them into a jungle without a native guide. They get biopsy and test results now online before meeting with me and are lost, worried, and scared. And this is allegedly progess.
I totally agree. I’m also part time no surgery in ENT and the pressure is gone. Looking forward to leave altogether the ruined medical system.
72 YO FP. I never want to retire. 12 years ago I was working 84 hours per week, currently I’m down to 28. I went from being an owner to being at the same level on the organizational chart as the janitor (who turns out to be a very nice Spanish-speaking lady). I am content and happy, especially when I have plenty of time for every patient. I have enough time for recreational reading, exercise, non-medical study, CME, gardening, and fishing.
To all the PCPs reading this who are burned out. Transition to a concierge practice so you can take full
control of your schedule and finances. You cannot care for a 2000-3000 patient panel and expect to give excellent care and not become cynical and burned out. It’s all about how many patients you are seeing in a day. I see less than 8 a day, and I don’t mind doing the stupid EMR and occasional prior authorizations. Stop complaining and make the change. I did 10 years ago and my life has been so much better. I wish I had done it earlier.
There can only be one Taeho Kim – hello to my old classmate! I agree with you. Taking control and limiting one’s schedule is the only way to survive in the long term; my life and patient care got much better when I resigned all admin tasks, cut my clinic schedule in half, and stopped going to meetings! Doctors must learn to say “no” or be prepared to walk, which is hard to do when you have invested 15+ years in education/training and may be in debt. Easier when older and w more financial independence, but also part cultural as we are always taught to accept more responsibility without complaining. Change starts only when one realizes that acquiescence to the system benefits only the business of that system and not your patients…
Amen!!
Great realistic article.
73% of physicians are now employees of hospitals or corporate medical businesses.
They are told what to do and how many minutes they may spend with patients. They are pushed beyond their limits for the sake of “profit”.
The only way I lasted 38 years, before I retired in 2022 as a Gastroenterologist, was to quit being an employee in a large multispecialty clinic, and open my own GI practice for my last 13 years. I was then able to set my own schedule to 3-4 days per week and increase the time I spent with patients in the office by 10 minutes for consultations and follow up visits. I took the time that the patient needed because no one told me to go faster and charge more money. I was extremely busy, and still with wait times, because the patients really felt that I listened to them, and with their improved satisfaction of not being so rushed, they referred their many friends and family to me.
When I retired after a very rewarding but demanding career, I still loved what I did, but it was time to “smell the roses”.
Physicians today don’t all realize that at today’s expected pace as an employee, they will burn out sooner and retire earlier, and not enjoy their last years of their career. That is why the recent trend of physician employees has started to reverse, as employed physicians are starting to understand the autonomy they have given up and the toll it has taken on their mental and physician health.
I have always stated there is more to life than greed and making more money, and can now enjoy the latter years of my life, still with plenty of funds to keep going and now with increased time for travels and family togetherness.
As an “old-schooler” myself of 42 years, I could see the writing on the wall back in the 90s. I began to argue then that patients weren’t widgets and gadgets, they had needs extending beyond simply a diagnosis and requisite treatment. Who factors in patient connections as therapeutic in and of themselves? I haven’t seen a randomized study showing patients, whose physician or other healthcare provider comes in with a rolling computer, makes minimal to no eye contact, blurts questions, types answers, gives shortened conversations or curt answers to questions, and leaves the exam room in the required 15 minutes (or less) compared to the same patients whose physicians smile, chat, listen and attend to their concerns, maintain eye contact, offer suggestions, explain further therapeutics and perhaps even give a gentle pat of the hand or arm before concluding the visit, but I bet option 2 has hands-down evidenced-based better outcomes. Medicine has become a machine run by MBAs instead of MDs. Large corporations with little or no experience in the delivery of health care are imposing impossible metrics, and we are all required to jump the hoops. And while there is a place for them, mid-level providers are too often replacing the better-trained physician.
True healthcare workers don’t go into medicine only for the financial rewards it may bring. If that’s the case, chances are you aren’t a very good doctor, nurse, or therapist. I fear the system will have to fall completely apart for it to be rebuilt as it should be… a place for patients to feel cared for, nurtured, supported, and even
escorted to a peaceful death fi that be the ultimate outcome.
Our patients, we ALL, deserve medical providers that perform with integrity, skill, knowledge and compassion. That cannot be compressed into some one-size-fits-all timeslot, whether at the office or as an inpatient at a facility. Only when we are able to maintain our own internal metrics based on didactic and intrinsic knowledge, will “health” and “care” be able to be honestly used as a one-word noun .
Nicely written Jill. You are so right. But is anyone listening ? Nurses and Paramedics are striking in the UK for all same reasons our system is failing our patients in the USA.They have broken, underfunded, understaffed and under paid NHs quasi government and privately run. I wonder who’s pockets all the money fills. Its a disgrace on both sides of the Atlantic
CMS increased the value of these office visits, and in response medical groups are lowering what they will pay you for those office visits. The solution is for primary care to get away from the large medical groups where more value is placed on specialists and sub specialists and their work. This will allow for primary care to make the money that they deserve and lobby to get paid what they deserve.
Amen. I remember when patient care was sacred. The latest insult was a list of additional mandatory and documented screenings for peds patients that makes no sense and adds additional time away from face to face care. There is not enough time to do/ document the various busy bodies in their quest to insure all their own boxes are checked.
In Australia luckily we don’t have managed care yet.
So GPs can and do set up practices to run as they want, not corporations.
Does the USA not have the ability for a group of like minded doctors to set up an independent, doctor owned and run clinic?
The cost and complexity of medical billing is prohibitive. It was probably 10 years ago. I heard that it was US$80,000 per doctor for that activity alone never mind malpractice and other expenses plus of courts office staff.
Wow ok.
Here I pay AUD5,000 a year malpractice insurance.
Software for clinical notes, billing etc is only a few thousand a year.
Cost of pens paper etc is cheap.
So nothing really to stop docs doing it except for headache of employing people : )
Private practice trend in primary care is direct primary care and concierge medicine. Billing insurance is too costly for private practice
Makes sense. Here as well a practice started billing patients a monthly fee to be on the books.
Seems to work well.
The easiest thing here if you are busy enough is charge $10 a minute, and let the patients claim back what they can from the insurance company. It really shouldn’t be up to us to get the patients rebate.
Swiping a credit card is very easy……