Author: Sparhawk Mulder
Interview with Dr. David Mulder
Most people are quite aware that doctors lead busy lives. But more and more, doctors are being pushed to the limit. So we had to ask: who, or what, is at fault?
“Productivity” and Salary
The number one priority of any hospital, clinic, or health center, is profit. Even non-profit organizations need to make enough revenue to maintain and buy equipment, pay their staff. Most doctors have a rather high salary, regardless of their specialty. In order to pay more competitive salaries, health organizations expect higher “productivity” in relation to your hours. In basic principle, this makes perfect sense: people who work harder should get paid more. But if we look at how “productivity” is determined, and what the realities of meeting those goals are, we begin to see some problems.
The main factor of “productivity” is how many patients you see in the time you work, how efficient you are. But ask any doctor, and they’ll tell you that the expected efficiency is ridiculous. Some specialties, like geriatrics, are expected to see patients every 30 minutes, but most hospitals have doctors see a patient every twenty, or even fifteen minutes! According to Dr. David Mulder, “That’s about enough time to say hello and write them a prescription”. If anyone comes in with multiple issues or something complicated (and they will), the doctor is set behind for the rest of the day. Appointments are usually scheduled back-to-back, so if one patient takes ten minutes extra, then all their other appointments will start ten minutes late (unless they work into lunch, which is also very common). Doctors almost always work overtime, and aren’t paid for it (because they have a salary).
This high-speed system ends up rewarding staff for being “nasty, fast doctors who don’t listen to their patients”. Alongside making patients feel unheard and preventing them from giving elucidating details, this rush also makes dangerous mistakes more likely. To help prevent this, doctors must fill out “Quality Assurance” forms (more paperwork) about each visit, but these QA forms are often a ridiculously low bar to clear. They focus on how thorough the (supposedly 15 minute) examination is, but often ignore things like the accuracy of the diagnosis, giving the correct prescriptions, and other major factors of medical effectiveness. Of course no doctor would give a bad diagnosis for the sake of efficiency, but the system still seems to place money over care. This isn’t necessarily the organization’s fault: they need revenue to operate, and some operate on a razor thin margin (unfortunately, this is especially true for smaller health centers in poorer areas). But that doesn’t change the effect: penalizing methodical practice.
Studies show that doctors spend more time doing paperwork than actually seeing patients; specifically, for every one hour a doctor spends seeing patients, they spend 2 hours on average “charting”. Why?
Well, there are two main issues: the paperwork for billing, and the EMR system.
Charting used to be simpler. Not easy or quick, but simpler, “And then the government came along and made it much worse”, says Dr Mulder. Medicare and Medicaid, while incredibly important and useful for making sure people can get medical coverage at all, are both incredibly cumbersome for doctors. In order for a patient to get something covered, the doctor must fill out a “proof of complexity” form. This shows the government reviewers how thorough the doctor was in their examination and diagnosis (like a QA form), and also how complex the patient’s issue is. Higher complexity forms grant the patient more coverage, so doctors always want to bill at the highest level of complexity they can, but that also means filling out longer and more tedious forms. Deciding what level of complexity to bill at, and what to include in those forms, is decided with what Dr Mulder can only describe as “incomprehensible tables”. Insurance forms can also be fairly complex (though they usually also accept the same forms as the government, which does save time if the patient uses Medicare/Medicaid). Doctors are often expected to bill for a certain average amount per patient, called a billing goal, which often requires that they bill at higher complexity than necessary. Doctors sometimes see a bonus if they bill over their goal.
Besides the strong incentive for doctors to fill out the longest possible forms, the way those forms (and other medical information) are created, sent, and stored is also problematic. EMR (Electronic Medical Records) systems are...less than ideal. Dr Mulder said “The EMR as it exists today is a fiasco. I have never talked with a doctor who has worked with any EMR system that worked quickly”. EMR is definitely better than paper, he agrees, but the current systems (and there are multiple, as it’s a competitive and profitable market) are all very inefficient. They involve incredible amounts of button-pushing and scrolling, looking under countless categories and subcategories of symptoms, only to find that the symptom isn’t listed and must be typed in manually. Furthermore, not all organizations use the same system, so transferring histories and charts can be a challenge for patients.
What to do?
As we can see, some of the biggest problems in the practice of medicine come not from lack of equipment, knowledge, or experience, but from middle-management, poor design, and the prioritization of revenue in a capitalist system. People who aren’t doctors can have a huge impact on the practice, and here’s three ways they (and you) can have a positive one:
-Make or encourage policy changes. The current system the government uses is highly inefficient. It shouldn’t be completely removed (!), but parts of it need to be reworked.
-Develop more effective EMR systems. It’s a difficult set of requirements, but a fascinating design problem too!
-Improve the local economy. Areas with better economies have better healthcare, and when health orgs feel less of a crunch, so do the staff (although medicine will always be a busy job).
Thank you to Dr David Mulder for answering our questions and sharing some potential solutions.