A number of years ago I wrote a post about why your doctor always runs late. I have no idea where the link is, but the general idea is this: you only have so many hours in a day, and lots and lots of patients want to be seen. There are only so many primary care docs, and so many spaces on a schedule. So you schedule people as tight as you think you can get away with, and toss in some add-ons who call to be seen the same day, and generally hope that the couple of people who no-show will leave some gaps for catching up. My own schedule has a 45 minute lunch built in, but that never really happens, and all it takes is one person with pneumonia or chest pain or depression to throw the schedule out of whack. This is cold comfort to those who sit around waiting forever, the only consolation being once I’m in the room with you, I’m yours for as long as is needed.
My post on this phenomenon garnered the expected griping about the patient’s time being just as important as the doctor’s, etc., an idea that I appreciate but that is short-sighted. Doctors are, for better or worse, a limited resource, and patients are stuck competing for that resource. When someone demands to be seen immediately, it is another patient whose time they are taking. Of course, with our inefficient, non-science-based health care system, I can probably get you an MRI of your entire body done in a few hours, but I still can’t get into your room on time.
All that aside, real medicine—the good kind—takes time. It may only take me a few minutes to diagnose a cold, but it may take me several more to explain why antibiotics aren’t needed. In a more paternalistic system, the patient would be told, “You have a cold, go home and have soup” and shuttle out the door. In a harried, “bad medicine” office, you would probably be given some Miraculocillin for $10 a pill and sent home. But to practice good medicine, you have to sit and explain what your are recommending and why, and then sell it, because even though patients are competing for your time, you still want to keep them coming back, both for business reasons, and for medical humanitarian reasons. Practicing good, humanistic medicine is a lot harder than practicing bad medicine.
All sorts of things can toss a monkey wrench into the daily schedule, not just someone who is severely ill and needs extra attention. A patient may come in after a hospitalization, and after getting the story from the patient, I’ll have to log in or call the hospital to dig up records. I don’t expect someone to give me an accurate accounting of their prolonged hospitalization, so I’m left to do the detective work (which is usually interesting). I may have to fill out new insurance physical forms since patients often change insurance companies frequently. Each of these forms has slightly different requirements, and if I screw it up, the patient will pay higher premiums.
I may find a patient who seems to have a simple infection didn’t do well on an antibiotic, and have to look up local resistance rates to see what new data from the community can help me make a better choice. I may need to look up the latest recommendations for screening for one disease or another, or I may have to figure out if a patient’s insurance covers preventative care or not. I may need to set up a consultation with an expert, calling them to explain the situation and asking them to make room in their own over-crowded schedule.
The day-to-day practice of medicine, when done well, is complex because it deals with human beings. But it gets even more complicated.
Under our current system, I get paid for what I do, that is, I get paid based on the complexity of an office visit, and for any procedures that I may provide. Most doctors are not salaried, and the rates charged are essentially non-negotiable, based largely on the way big insurers such as Medicare and Blue Cross do things. I recently moved my practice 2.5 miles down the street. I can nearly see my old office from the window of my current office. Despite this, I have to re-credential (which is apparently a word, according to insurance companies) with Medicare, Blue Cross, and all of the other insurance companies that we work with. Even if they have current copies of my license, etc, they need them all again, and will take months to get me into their system at my new practice. I moved in December, and I was finally re-approved for a bunch of the smaller insurance companies. Medicare is still working on me. This means that my practice has not been paid for my work for the last three months.
Some would argue that this shows how dangerous a single-payer system would be: imagine if Medicare were in charge of everything! The converse is that dealing with a single entity would be a helluva lot easier than a dozen. The paperwork is astounding and expensive, and cuts into patient care. So while insurance companies push at doctors to adopt the latest model for reimbursement (with phrases such as “meaningful use”, “patient-centered medical home”, and “accountable care organization”) doctors are busy trying to see patients, and trying to not lose money by doing so.
I’m cynical enough to know that there are problems with a single-payer model, but from the standpoint of a patient and of a busy practitioner, the paperwork couldn’t get any worse. And from a social justice perspective, it’s a no-brainer.