How to survive in medicine and preserve our motivation
by E. Jeanne Kroeker, MD —
At the interim meeting of the AMA House of Delegates earlier this month, AMA President Jack Resneck, Jr., MD, identified numerous challenges faced by physicians right now. Looming Medicare cuts at the end of this year (and seemingly every year), the COVID-19 pandemic and its ongoing economic and physical impacts, the intellectual pandemic of disinformation and misinformation with mistrust of science, government interference in practices, and insurance interference in practices ALL pull us “away from what drew us to medicine in the first place — caring for our patients.”
As Dr. Resneck stated, “Medicine is complicated, and doctors didn’t pick this career because it’s easy. What makes the practice of medicine interesting are the uncertainties of diagnosing and treating patients and how each patient brings their own preferences and values into the equation.” However, how each patient brings their internet-garnered pearls of wisdom and social media “facts” into the equation is not what most of us ever expected to face. The unyielding, proscribed decision trees of insurance approval for advanced imaging or medication choices or procedures are not what make medicine interesting or engagingly challenging. Uncertainties do not fit into a decision tree on a flow chart.
In the last 10 years, physicians have seen a daunting increase in unfunded mandates and so-called quality metric reports that take an inordinate amount of time to generate but do not contribute to patient care in any meaningful way. Our notes must be complete according to insurance and corporate guidelines and not according to appropriate consultative needs, nor even serve as an adequate record of care. Trying to find out what a consultant is recommending requires sorting through pages and pages of MIPS statements and declarations in the middle of the consultation note.
Insurance companies requiring diagnosis codes for every bit of provided medical care coupled with mandated open records is arguably worsening patient-physician relationships. Disease names are being applied, usually as a supposition, while workup proceeds because symptom codes are often denied by insurance. Patients see those names and are later confused and angry when this label is identified as a guess and revealed to be incorrect as the appropriate workup unfolds. ED notes and hospital discharge summaries are littered with diagnosis codes that are technically correct but clinically irrelevant. How many times each week do I have to explain why “AKI” is on the ED report of a patient who had an elevated creatinine level but no actual kidney injury? How many extra letters are generated and sent to a primary care doctor for every blood pressure reading out of an ideal range, even when this minor elevation is not clinically significant?
In his AMA speech, Dr. Resneck also specifically named prior authorizations as a painful, onerous and frustrating part of every practice, contributing to physician dissatisfaction and burnout. He declared that the AMA would work to demand streamlined and fewer prior authorization requests from payors. Constantly asking for permission to provide appropriate care from an insurance company or PBM unwilling to pay for appropriate care, in a medical system where the ability to self-pay for such care is prohibitive, provokes anger in even the most unflappable physician. One of my co-workers just had a prior authorization denied without explanation for standard-dose simvastatin, an inexpensive, generic drug that has been commonly used since the famous 4S trial of 1994.
Equally frustrating is when evidence-based treatments are eschewed time and again by immediate care clinics, typically staffed by non-physician health care workers, seeking patient satisfaction scores more than appropriate care. Or when patient health care costs are blatantly ignored in these same clinics with unnecessary labs and imaging performed to make it look like there was a lot of effort expended to provide excellent care. I have patients who expect every lab test known to man to be done every year because that is what they get in an “Executive Physical,” assuming that more testing means better health. And if I don’t provide this care, they will find a clinic that does.
What can we do to preserve our motivation to continue to provide appropriate and enthusiastic medical care to our patients? We can continue to fight back against insurance denials; we find cheaper medication sources or medication coupons; we get to know the imaging facilities with cheaper patient costs; and we support the efforts of organized medicine to define best practices and less-inhibited care. But all of these things take time, without any reimbursement. If you provide support for the AMA, your specialty organizations and societies, or even your own clinic teams, you can lead or at least have a voice in the charge to better care with better practice conditions. Your membership in MSSC and participation in MSSC events can also amplify your voice and your efforts.