Monday, October 8, 2012

Medicine needs to join the 21st century

Last week, I wanted to start a new medication for my patient.  Her insurance company didn't want to cover it.  So, I called her insurance company to argue my side.

After listening to some awesome (not) hold music, I got to speak with an automated system that asked for information about me and my patient.  Okay, this was kind-of impersonal, but it wasn't particularly offensive to me.  Then more awesome (not) hold music to speak with a "representative."

The representative introduced himself by his first name.  Perhaps he was having an off day, but his customer service skills were a bit lacking.  He also appeared to have very little medical knowledge; he read through a list of conditions that this particular medication is approved for, mangling most of the pronunciations.  After answering "no" to this list of 20+ conditions (and assisting him with pronouncing most of them), I was put on hold again.  Yep, more awesome (not) hold music before being informed that the pharmacist declined my request. Next step: wait on hold again to finally speak with a physician in peer-to-peer review.

I want to be responsible with costs for my patients and the health care system. I'm sure at times I am wrong, and a more affordable alternative with equal efficacy exists.  It's not that I'm unwilling to hear that - I would just desperately prefer a more efficient way. I didn't need an insurance company representative to tell me that my request wouldn't meet their usual criteria, but I had to be officially "denied" before I could speak with a doc who could override it.  Why must policing medication costs involve sucking time away from busy primary care docs who don't have that time to spare?

Although I am unhappy with this particular episode, my goal is not to vilify insurance companies; they also have a job to do, and many of my patients benefit from their services.  Let's face facts; physicians are our own worst enemy when it comes to the outrageous spending on health care in the U.S.*  As physicians, we need to stop blaming the insurance companies for the need for these reviews and take responsibility for the costs of what we prescribe.  We need to encourage better interfaces among all players in the health care area.  Our patients need us to work collaboratively with insurers to make their care better.

Insurers' scrutiny of our prescribing is not likely to go away any time soon, though, yet the problem with these medication reviews is not the company representatives or the awful hold music; it's the phone process itself.  It's the 21st century, yet we're using the telephone like it's 1950.  Maybe that nifty 20th century invention, the computer, could do better...

How about an automated cost-rating system for physicians within insurance companies? Maybe if you're a "red flag" doc who frequently prescribes unnecessarily expensive drugs and treatments, then you have to be go through peer review more often and maybe even do some extra CME on cost containment.  If your track record shows mostly low cost interventions, though, then perhaps you get a free pass or two.

How about an online review process?  Insurance companies could be super-transparent about the covered conditions, and if your request didn't fit, docs could immediately send a HIPAA-secure message to peer review.

Health care reform must include simplifying the processes that waste resources; and, yes, physician time is a valuable resource.  This frustrating, inefficient process of getting medications approved is among many others contributing to our skyrocketing costs, aggravating insurers and docs, and discouraging students from a career in Family Medicine.  We will need more family docs in future years, not less. And, we will need them actually practicing Family Medicine instead of listening to awesome (not) hold music on the telephone.  

Surely, together, we can find a better way.
CME = Continuing Medical Education.  Most medical specialties require so many hours of CME every year to maintain your board certification.
HIPAA = Health Information Portability and Accountability Act:

Wednesday, October 3, 2012

Burnout & redemption

I didn't consciously decide to put my blog on hiatus these last few months.  I just got too busy one week to post, and then the next week, and then the next...

I admit to getting overwhelmed with some professional and personal challenges during this time.  Part of my unintentional blog hiatus was certainly related to those issues; they were the only things I could think about, yet I didn't want to share them on this blog.  The only problem was that those challenging situations were what I needed to write about.

The professional stuff, well, just isn't appropriate to share in a public space.  And, as for the personal stuff, I wish that I had the courage to share the details of my life with you all, but I don't.  I love reading the medical bloggers who are bold enough to let us peer into their lives, and  I'm grateful for their courage.  Through their stories, we gain a deeper appreciation of our humanity.  Blogging about the specifics of my personal issues, however, is just not for me.  I'll reassure you that my health and marriage are fine, and that will have to sate whatever curiosity you might have.  :)

As I look back on those four months, though, I recognize that more was going on than just challenging situations.  I became emotionally overloaded.  The trivial annoyances of my job became herculean, and I struggled to find the joy in being a doctor.  It took more and more emotional energy every day to rally up a positive facade with my patient care and teaching.  I felt like I was stuck in an impossibly deep rut.  I was burnt out. Would I ever love my job again?

These feelings are fairly prevalent among physicians.(1)  Primary care docs, especially, report higher levels of burnout than our specialist colleagues.(2)   So, what's a burnt out doc to do?

Well, from the JAMA article below: (1)

Strategies to Prevent Physician Burnout 
Influence happiness through personal values and choices
Spending time with family and friends
Religious or spiritual activity
Self-care (nutrition, exercise)
Adopting a healthy philosophical outlook
A supportive spouse or partner 
Control over environment: workload
Finding meaning in work and setting limits
Having a mentor
Having adequate administrative support systems

Easy, right? *insert sarcasm here*  These goals are great thinking about long term and the big picture, but what about for when you're stuck in that rut?  How do you clamber out?

I can only speak for myself, but I was pulled out of my rut this past weekend at the Family Medicine Education Consortium annual conference.  700+ family docs - and future family docs! - provided a whole lot of positive energy around our collective efforts to improve health for our patients and communities. They reminded me about why I felt called to this profession in the first place: I get to combine my science geek-ness with my drive to contribute to making the lives of those around me better.  I get to interact with amazing people who inspire me push the envelope even farther.  I get the joy of being a "friend with special knowledge" (3) to my patients, and I get to contribute to future family physicians' educations, ensuring that they will deliver quality health care to the generations to come.

For the long term, those strategies above are worth championing, but for the short term, try some time away from the office with your tribe.

Good-bye, rut.  I'm back.

(3) The kind of doctor John Steinbeck wanted: