Evidence-Based or Hassle-Based Medicine?

Recently, I was at a party with four primary care physicians—two internists and two family practitioners. Each was less than 40 years old.

As have other recent conversations I’ve had with physicians, this one revealed the doctors’ strong feelings of job discontent and frustration. Being a young physician was not what any of these talented and caring people thought it would be. Their ideal of helping other people both physically and emotionally while providing resources and leadership for their families and communities seemed naïve despite the fact none of them had yet had their tenth medical school reunion. Particularly sad was that all four of these young doctors questioned their decision to practice medicine, and one was seriously considering changing to a different career.

Similar conversations occur these days among doctors in all medical specialty areas, including endocrinology. What has gone wrong?

This is a very complicated topic. On the surface, the overwhelming complaint is the ridiculous amount of paperwork physicians are now asked to complete. The number of forms and letters required has increased substantially (perhaps exponentially) during the past decade. Certainly, much of this can be attributed to managed care policies and the unending additional forms required for Medicare patients. Physicians who care for many patients with diabetes are particularly punished because this population requires so many additional services, medications, and supplies.

The amount of unnecessary paperwork required by some managed care organizations is legendary. For example, one insurance carrier asks to see 3 months of food records before considering coverage for an insulin pump.

That’s 3 months.

Each gram of carbohydrate.

No exceptions.

I’m still waiting for the insurance company to ask to have these food records notarized. At least for now, we have been spared that particular “hoop.”

How many times in the past year have I been asked to sign a form stating I agree to participate in the “cost-saving measure” of using one proton pump inhibitor instead of another? And how much time do we all spend completing the forms that allow our Medicare patients to purchase their home blood glucose supplies? Even for those who are fortunate enough to have personnel to complete the forms, how much does this paperwork cost their practices?

I recently completed a form and wrote a separate letter requesting a walker for a stroke patient. Apparently, I did not use the correct wording. I wrote a second letter. Several months passed; still no walker. I wrote a third letter, but before the walker arrived, the patient fell. Fortunately for both the patient and the procrastinating insurance company, she did not fracture any bones.

The rationale for some of these paperwork adventures is that we will practice a better quality of medicine, particularly more cost-effective medicine. But what is the cost of being so cost-efficient? Are we actually doing a better job of practicing evidence-based medicine? Is the quality of medicine actually significantly better now compared to 10 years ago because we have more paperwork?

Of course not. The real issue has to do with the cost of medicine and the fact that in this “for-profit” world of managed care organizations, pharmaceutical companies, and even physician groups, we are all being asked to “increase productivity” to maintain the “bottom line.” The cost of practicing medicine has increased, and we are being asked to complete more forms in an attempt to slow it down. I am not in a position to know whether this strategy is effective. But what I do know is that many, if not most, physicians are beyond frustrated with our current system.

Diabetes is just one of several costly chronic disease states for which new therapeutic advances have further increased the costs. Certainly, no one would argue that we should encourage cost-ineffective treatments. Indeed, it has become quite clear that aggressive treatment of type 2 diabetes is cost-saving within only 1 to 2 years.1 Why, then, do our systems seem to be fighting us in our efforts to achieve these improved medical and cost outcomes?

Many physicians I have met are hopeful that their college-aged children will not choose a career in medicine. The many hassles of medicine—and particularly the increased amount of paperwork—have left many of these doctors, who are now at the end of their careers, disappointed in the way the practice of medicine has evolved.

I enjoy seeing patients, but I agree that it is more difficult now than it was 10 years ago. I don’t have any solutions except to follow the advice of one wise internist who said, “Never let a piece of paper cross your desk twice.”

In another 10 years, perhaps we will be completing all of our forms online. Alternatively, items such as employment physical exam forms, disability forms, and Medicare durable medical equipment forms could be completed on one’s personal digital assistant, which could then be “beamed” to a secretary for processing and mailing. It seems to me that technology should help us become more efficient in carrying out our administrative burdens and leave behind the mess we have now.

No one could have predicted that the practice of medicine could become so cumbersome. As we pursue the promise of evidence-based medicine, we can only hope that our current hassle-based medicine improves.