Recently I faced consoling a patient of mine who couldn’t understand why I was unable to “hop on the phone” to discuss her new back pain. When she finally got an appointment with me weeks later, I decided to be honest. I shared that I had 1,300 patients who call me their primary doctor. After I’m done seeing patients at 5 PM, I tend to 50 to 100 messages and notifications. I take three to four hours of work home with me every night.
I didn’t share these stats to elicit sympathy, but soon our roles had reversed. My patient overflowed with apologies and demanded to know who was doing this to me.
This is the paradox that defines modern American medicine: Doctors are working harder and longer, all while patients can access us less. As a practicing internal medicine physician and oncologist, I believe we reached this unsustainable state due to fundamentally misaligned division of labor – between human and machine, between doctors and support staff, and between what is paid for and what good medical care requires.
As a doctor, I am no stranger to hard work. But the ways doctors’ workloads are exploding are largely clerical and bureaucratic. Ironically, a big culprit is electronic medical records. Paper records were converted to electronic charts over a decade ago, with the incredible potential to connect enormous amounts of patient data seamlessly. However, the very technology that was supposed to reduce doctors’ work has drastically increased it. Doctors today spend two hours doing computer tasks for every one hour facing patients. Ordering something as simple as Tylenol requires doctors to click between fourteen and sixty-two times, with the confusion causing errors in up to 30 percent of cases. The number of clicks in one ten-hour shift in the emergency room approaches four thousand. Nearly 60 percent of doctors’ notes are identical, and therefore redundant, to the previous ones. The practical result is that doctors spend hours digging through disorganized charts, sleuthing for critical patient data that gets buried under an avalanche of noise. In an era where multibillion dollar software promises to ease data-sharing, the process for providers to input and find health data remains manual, labor intensive, and error prone.
Our current solution to these technologic glitches is leaning on people to serve the needs of the electronic charts. It was supposed to be the other way around. Support staff becomes crucial, yet patching logistical holes often falls to doctors. Recently I prescribed a medication that took 22 clicks, waiting on hold with an insurance company, tracking down a denial letter, writing an appeal, documenting all these phone calls, and keeping my patient apprised through messaging. How many of those steps needed to be done by me? In my estimate, only about half of my daily work actually needs to be done by an MD. The best run clinics understand this and train medical assistants to do much more than stock clean gowns and take vital signs. These clinics also hire nurses who can manage tasks such as refilling prescriptions, triaging patient calls, and answering messages. But while team support and delegation has caught on in the hospital setting, it lags in primary care where the doctor often plays all roles at once.
Managing a patient’s case in this fragmented system requires better tech and team support. It also requires time. In comes the final mismatch: between what is paid for and what medical care requires. Despite pushes in recent years for payment models that focus on value, the vast majority of health care organizations in the U.S. still operate according to fee-for-service. Here, health organizations or doctors get paid based on discrete services they provide. In primary care, that service has been commodified into the office visit. Nothing else directly counts as paid work: not communicating with patients in between visits, not following up on test results, not digging through medical records, and not discussing cases with other doctors. Moreover, fee-for-service generally reimburses more for visits with new patients than appointments with patients following up. With the financial incentives stacked to book as many patients as possible in face-to-face visits, appointments get compressed to fifteen minutes and a typical primary care doctor’s panel swells to over 2,000 patients. All the extra works spills into doctors’ off hours. Meanwhile, each patient competes against thousands for coveted appointments. When attempts to secure timely appointments fail, patients turn to messaging, moving the deluge for doctors to another uncompensated channel that many practices are now trying to disincentivize by tacking on a charge.
The result is a perfect storm that drives good doctors out of traditional medical practices while patients lose outlets to communicate with them. I wish I could have called my patient. But doctors must pick their poison: they speed up and miss important details, spend their nights and weekends carrying over work, or leave. The options for leaving include going part-time (because everyone knows the secret that part-time is actually full-time), joining concierge practices that cap at 200 patients compared to 2,000, or quitting medicine entirely. Patients who can’t get appointments navigate their own lose-lose options: they try to self-manage medical concerns, turn to urgent care or emergency rooms for non-emergency issues, or get billed when they send messages asking for help.
Fixing this crisis will involve profoundly rethinking how we allocate the resources we already have. For years, the labor needed to assemble disparate pieces of a fragmented health care system continued to climb, while the party line to doctors remains the same: Just one more thing. One more click. One more message. One more workaround. Just squeeze it in, we don’t know how, but do it anyway, and do remember if anything goes wrong the responsibility is fully yours. This way of thinking is why primary care doctors are tasked with squeezing 26.7 hours of work into a single day. It is why nearly half of doctors report burnout with bureaucratic demands the number-one cause (this stayed true both before and during the Covid pandemic). And it’s partly why the average wait to see a new doctor is 26 days and getting longer. Some fixes like changing payment models will be harder to spread. But other improvements, such as training staff to tackle clerical work and investing in quality improvement initiatives to augment the technology, can be made now. With every proposed innovation, we must finally take seriously the questions: Does this help doctors or make their lives harder? Will this let doctors know their patients better or deepen the divide?
For a doctor who has led life-and-death emergency responses to talk so fervently of paperwork and scheduling might seem ridiculous. It is. But ignoring the mundane is how medicine reached this untenable state; putting it off any longer is costing us time, energy, and lives.
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