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Friday Apr 18, 2014

Tedious Paperwork, Government Regs: Why I Still Love Being a Physician

Today I had a busy day with a full schedule of patients. I struggled to chart my patients' complex histories in an electronic health record that has given me none of the efficiencies it promised.

I lost my lunch break to an administrative meeting, leaving me no time to get caught up from a hectic morning.

I filled out prior authorization forms for medications that a patient has already been on for six months. I completed more forms and insurance paper work than I care to remember and bemoaned the low reimbursement we are being paid for our visits.

I came home hoping to squeeze in time with my family but knowing that I also had hours of catch-up charting to do. 

When I left clinical medicine for a year, I discovered that I wanted, and needed, to come back.

This is a typical day for me, and I'm sure other physicians can sympathize. There are a lot of reasons to feel frustrated as a doctor right now, and a recent article written by an internist in The Daily Beast(www.thedailybeast.com) outlines how difficult the job can be at times.

But I still love being a doctor, and -- despite the challenges, the paperwork and the burdensome regulations -- I know I'm not alone.

Next month will mark 10 years since I finished medical school and started my journey as a family physician. After residency, I worked at a federally qualified community health center, seeing patients from a wide range of cultural and socioeconomic backgrounds. It often seemed like my patients' problems were bigger than my prescription pad because I couldn't cure the poverty that was at the root of their medical conditions.

I thought I could do more for my patients outside of the examination room than inside, so I left clinical medicine. I spent a year in the federal government as a White House Fellow. In one sense, it was a breath of fresh air: no insurance forms, no call, no charting or EHRs and no worries about whether or not the sustainable growth rate (SGR) was going to be fixed. In addition to gaining a better understanding of how the government works, I also had the opportunity to work on issues such as breastfeeding, hunger and poverty at a national level.

When I started the fellowship, I didn't know if I would return to clinical medicine, but it didn't take me long to realize how much I missed seeing patients. I found myself seeking out clinical experiences, asking anyone with the sniffles if they had other symptoms or if they were taking any medications.

After a year away, I was excited to jump back into patient care. Providing primary care to patients is truly my calling.

I have to admit, I'm a glass half-full kind of person. Although I recognize all of the problems we face in medicine, I also see so much to be excited about.

The Daily Beast columnist pointed out that the majority of medical students typically pick high-paying subspecialties. She also wrote that primary care physicians are the janitors of the medical profession. How nice. The fact is that the number of medical students choosing family medicine has increased for five years in a row, and the number of U.S. medical graduates picking our specialty also is increasing.

It's true, however, that payment -- one of the AAFP’s top legislative priorities in Washington -- remains an immense challenge, both to our practices and to building student interest in family medicine. In a recent MedScape physician survey(www.medscape.com), family physicians ranked near the bottom of the physician salary scale, yet we had one of the most positive responses when respondents were asked if, given a chance, would they would chose a career in medicine again.

So what do we have to be optimistic about?

I am encouraged that for the first time there is a bi-partisan, bi-cameral proposal for a long-term SGR fix. (Congress hasn’t got the job done yet, but there is still hope.) And CMS, with input from the Relative Value Scale Update Committee (RUC), continues to address overvalued procedures, which shifts money within the Medicare fee schedule to other services, including those commonly done by primary care.

Last year, CMS created two new codes to cover transitional care management, and next year the agency plans to add a code for chronic care management. These new codes should benefit primary care physicians.

I also am hopeful about the prospect of alternative payment models that may actually reimburse physicians based on the value of care that we provide and not the number of people we see (a backwards system that incentivizes physicians to do more and increases medical costs). In addition, more and more practices are operating outside of the insurance framework altogether by providing direct primary care(www.dpcare.org). This option is affordable to patients and puts the patient back in the center of the cost equation.

I am intrigued by the fact that technology and telehealth have the potential to revolutionize how we see patients and provide comprehensive care. Patient portals and virtual medical visits offer opportunities to reduce office visits and increase patient satisfaction.

It has been a joy to see so many patients who are now able to access care with me because they have insurance through the Medicaid expansion created by the Patient Protection and Affordable Care Act.

And for all of the political drama that health care reform has created, it also has opened up a real conversation about the strengths, weaknesses and future directions of health care in the United States for the first time in decades.

But the real reason I still love being a doctor is my patients. So although I could look at today as a tedious mess of charts, forms and administrative haggling, instead I see it as a tapestry of patient experience. I will soon forget the paperwork, but I won't soon forget talking with my patient as we learn her cancer may have returned, or congratulating my patient who lost 20 pounds and dropped his cholesterol by 50 points, or helping a couple start the process of adoption after a long battle with infertility.

In the Medscape survey, the average salary of all physicians was more than $200,000. Eight subspecialties had averages of more than $300,000. Yet when asked what the most rewarding part of their jobs was, only 10 percent of physicians cited money. The top response was "being good at what I do" at 34 percent, followed closely by relationships with patients (33 percent). "Making the world a better place" was third at 12 percent.

So what do I say to physicians who are burned out or dissatisfied? Perhaps it's time to look at other job options? Or maybe it's time to just take a break. When I left clinical medicine for a year, I discovered that I truly love it. It confirmed for me that I wanted, and needed, to go back.

But to do so, I had to do it in a way that was sustainable for me and my family and still allow me to enjoy patient care. That decision sparked my interest in joining the AAFP Board of Directors because I want to help make the world of medicine better for family physicians.

The profession of medicine truly is a calling to help others. I came into it knowing that sacrifices would occasionally have to be made and that patients would often have to come first. If one is in it for money or accolades, he or she likely will be disappointed. I find joy in being able to help my patients navigate their lives in sickness and in health so that they can get back to the joy of living.

Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.

Posted at 03:03PM Apr 18, 2014 by Kisha Davis, M.D.

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