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It's enough to make them say 'aaaah!'

Family doctors are overwhelmed with patients, procedures and paperwork. Some of their services aren't paid, and many are leaving the field.

June 27, 2011|Cathryn Delude

The days of the old-fashioned family doctor who knows us intimately and treats our kids -- and our grandkids -- are fading fast. Instead, we're more likely to find ourselves searching for a doctor who will take our insurance, then waiting weeks for an appointment and hours in the waiting and exam rooms. Our doctor will rush in and rush through a series of pokes and prods and a checklist of questions, check off some codes on our record, then rush out again. None of this makes us very happy -- or, for that matter, the doctor either. Primary-care doctors take care of the young, the old and the in-between; the sick, the well and the dying. Ideally, they're familiar with us and our family history, have a comprehensive overview of our various ailments and medicines and provide us continuity in the world of fragmented medical specialties. But their trade, they say, is getting trickier and more time-consuming, and that's fast making them an endangered species. Patients, they say, want more from their doctor these days -- more office hours, more email and phone contact, more follow-up, more coordination with specialists and insurers, more discussion about options and more expertise on more topics (aided and abetted by that constant TV-ad refrain, "Ask your doctor if X is right for you"). And the healthcare system expects more of doctors too -- more preventive services, more care for chronic diseases, more healthful lifestyle coaching, more screening for depression and risky behavior (guns? cigarettes? bike helmets?), more delicate discussions (prostate biopsy? end-of-life wishes?), more documentation and now electronic records too.

For The Record
Los Angeles Times Tuesday, June 28, 2011 Home Edition Main News Part A Page 4 News Desk 2 inches; 104 words Type of Material: Correction
Family doctors: An article in the June 27 Health section on the increasingly busy lives of primary care doctors quoted Dr. Mark Friedberg as saying, "I write letters to the electric company on behalf of my diabetic patients, pleading with them not to turn off the power. The cost to the system would be just too great if the insulin pump failed." Friedberg notes that most insulin pumps are battery-powered, but patients need light to set the correct insulin dose (whether using an insulin pump, syringe or pen). He added that power shut-offs also cause problems for patients requiring asthma nebulizers and refrigerated medications.
For The Record
Los Angeles Times Thursday, June 30, 2011 Home Edition Main News Part A Page 4 News Desk 2 inches; 67 words Type of Material: Correction
Primary care doctors: An article in the June 27 Health section about the increasing number of tasks family physicians must perform stated that there are more than 100 primary care practices in the U.S. that are patient-centered medical homes, a new model for primary care. To date, 2,314 patient-centered medical homes are recognized by the National Committee for Quality Assurance, a nonprofit that evaluates health delivery programs.
For The Record
Los Angeles Times Monday, July 04, 2011 Home Edition Health & Wellness Part E Page 4 Features Desk 4 inches; 156 words Type of Material: Correction
Family doctors: An article in the June 27 Health section on the increasingly busy lives of primary care doctors quoted Dr. Mark Friedberg as saying, "I write letters to the electric company on behalf of my diabetic patients, pleading with them not to turn off the power. The cost to the system would be just too great if the insulin pump failed." Friedberg notes that most insulin pumps run on battery power, but patients still need light to set the correct insulin dose (whether using an insulin pump, syringe or pen). He added that power shut-offs also cause problems for patients requiring asthma nebulizers and refrigerated medications. The article also said that there are more than 100 primary care practices in the U.S. that are patient-centered medical homes, a new model for primary care. To date, 2,314 patient-centered medical homes are recognized by the National Committee for Quality Assurance, a nonprofit that evaluates health delivery programs.

Numerous studies have found that when primary care works well, patients are healthier, with better management of chronic diseases and fewer emergency-room visits and hospitalizations. All that saves healthcare dollars too.

But many doctors say there is not enough time in a typical 15- to 20-minute office visit to cover all the tests, inquiries and procedures recommended by medical schools, the U.S. Preventive Services Task Force and other organizations -- even when dealing with a healthy patient.

"It's almost overwhelming," says Dr. Christine Sinsky, a primary-care physician at Medical Associates Clinic and Health Plans in Dubuque, Iowa. "I think many of the new expectations are laudable and yet can't be delivered by one person working all by themselves."

And so doctors must give some things short shrift. A conversation about prostate cancer screening that would ideally take 10 minutes gets maybe a minute, says Dr. Mark Friedberg, a researcher at the Boston office of the nonprofit Rand Corp. who practices two mornings a week at a Brigham and Women's Hospital clinic in the Massachusetts city. "Physicians don't have time to really do optimal primary care," he says.

The situation is worse, he adds, when you factor in the increasing number of patients with complex conditions such as asthma, diabetes, obesity or heart disease. They require more frequent visits, and the list of steps recommended for their care is steadily growing.

Rushed office visits are only a part of the problem: Growing too are activities outside the exam room. Every prescription refill request should trigger a review of a patient's medical records. Every lab test, imaging result and specialist report should be interpreted in light of the patient's overall treatment plan.

Doctors are now meant to keep registries of patients with chronic diseases and periodically reach out to them to make sure their conditions are managed.

"It's common to have two hours of documentation work to do at home after the kids are in bed," Sinsky says -- and there's no formal way to bill for these tasks or receive productivity Brownie points for doing them.

Studies back up these doctors' gripes. It would take 10.6 hours a day for a physician to follow all the treatment recommendations for patients with 10 common chronic diseases, including diabetes, heart disease, high blood pressure, depression, asthma and arthritis, according to a 2005 study in the Annals of Family Medicine. That doesn't leave much time for a 6-year-old's school physical or his mother's brush with the flu.

Activities outside the exam room consume about 20% of a primary-care doctor's workday, according to a physician survey reported in the Journal of General Internal Medicine in 2010. This tally includes telephone and email interactions that often substitute for office visits.

Many of us prefer these virtual visits: Our time is precious too. But they are a problem for doctors because most healthcare insurers, including Medicare, reimburse doctors only for face-to-face visits, a payment model called fee for service. And even many aspects of office visits are essentially free, because primary-care doctors must bill for their time using only five codes for Medicare and most commercial insurers.

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