Letter to the Editor


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To the editor:

When I was 20-something, I recall being bored by the old duffers who yearned for the good old days. Now I'm 53 and find myself craving for the way things used to be.

Nowhere is this desire stronger than in my practice of medicine. As a newborn specialist, I've had to become familiar with the conditions imposed by managed care. I am now accustomed to begging an insurance company for an extra day or two just to be certain that a premature baby is strong enough to eat adequately before I discharge him from the hospital.

But my physician colleagues and I are not just contending with managing our patients' care according to a third party's set of standards. We also are struggling with how to manage our time so we do not shortchange our patients and yet meet the ever-increasing requirements imposed by the government and insurance companies.

A complex new set of federal regulations has added an average of three to four hours to each day I am in charge of the newborn intensive-care unit. These regulations were developed by the government in an attempt to curb fraud in our nation's health-care delivery system. I don't deny that medical fraud exists, and as a taxpayer, physician and lawyer, I certainly applaud reasonable efforts to eliminate it. However, when these regulations begin to impact the way the doctor delivers medical care, I remain unconvinced that this type of approach will serve the patient well.

The depressing fact is that these extra three to four hours daily have had no impact on my actual care of patients. Rather, I spend the extra time with each patient's medical record making certain that, according to an artificial scoring system, it accurately reflects each procedure or service rendered that day. The regulations have not made me a better physician, only a more voluminous scribe.

Malcolm Sparrow, author of "License to Steal," contends that current "controls are extremely useful for correcting providers' honest errors, but ineffective as detection apparatus for criminal fraud." Sparrow also notes that "fraud control flies in the face of productivity and service and competes with them for resources.

In my old days as a general pediatrician, I could always find time to spend with a family or child who really needed me to help sort through a complex issue. Now I feel fortunate if I don't offend someone by being so preoccupied with my paperwork that I don't recognize when a patient's family needs some additional moments of my time.

Currently, physicians suffer no criminal penalty for spending an inadequate amount of time with patients. Academic physicians fear no threat of punishment if they spend too little time teaching students and residents or conducting research. The risk of fines or imprisonment comes from not completing all the forms and paperwork and not complying with the mounting number of requirements coming from regulatory agencies and insurance companies.

Physicians are increasingly frustrated by the seemingly endless need to document. In her recent visit to Columbia, the president-elect of the American Medical Association summed up physicians' concerns when she said, "Do you want me to take care of the patient, or do you want me to create this lovely piece of paperwork?"

In response to the requirements heaped upon physicians, the dean of the University of Missouri School of Medicine recently assigned me the responsibility of making sure the physicians and support staff at the University of Missouri Hospitals and Clinics are knowledgeable and in compliance with the various regulations mandated by outside agencies. This position didn't exist in an academic health center even one year ago. Now such oversight has become necessary to ensure we are following the rules enacted by external agencies.

What does all this mean for patients? It means someone else is dictating how your doctors spend their time. It means your physician may appear to be more rushed the next time you visit him or her because of the mound of paperwork that is waiting. If you are a managed-care patient, it may mean your HMO has indicated how many patients your doctor should see each day and even how much time each visit should take.

Dr. Joseph Scherger writes in a June 1997 editorial in Family Practice Management, "The wisdom of the ages has shown that two of the most important parts of treating illness are time and the doctor-patient relationship. These two therapeutic tools are getting lost in the new delivery systems."

Achieving successful medical diagnosis and treatment takes more than tests, technology and knowledge. It take communication between the patient and physician. It takes a physician who has time to listen and to ask questions. It takes perception, empathy and compassion.

If I yearn for those measures of performance rather than the productivity quotas and documentation standards of today, then call me an old duffer.


University of Missouri Health Sciences Center