As Charles Dickens might say about the practice of medicine in the twenty-first century: it is the best of times, it is the worst of times. We live in an age of astounding technological and pharmacological innovation and discovery. Our ability to diagnose and treat disease has never been better. We are on the threshold of being able to diagnose cancer from a single abnormal cell and have transformed life-threatening and life-altering diseases to chronic disorders with minimal morbidity. The introduction of biologic drugs has dramatically changed the expression and progression of disease.
As a rheumatologist with more than 30 years of clinical experience, I have witnessed these dramatic changes. Rheumatoid arthritis, a potentially devastating and crippling disease, has become, in many instances, a disease devoid of significant morbidity. The introduction of biologic therapies can greatly reduce and often halt joint destruction and deformity. Indeed, the incidence of joint replacement surgery due to rheumatoid arthritis has been greatly reduced. But we have paid dearly for these advancements, and the cost has been the time, effort, and expense needed to obtain authorization for their use. That time often comes at the expense of time spent with patients.
N.B. is a patient with rheumatoid arthritis whom I have been treating for more than 20 years. In our early encounters, I was able to spend as much time with her as I needed in each interaction, getting to know her as a whole person, including the emotional factors that could impact her disease. We developed a successful therapeutic relationship partly because I had the time to spend. I attended her surprise eightieth birthday party and helped her face the devastating and depression-inducing death of her husband. I played the role of psychiatrist as much as that of rheumatologist. But, in more recent years, our interactions have become shorter. More and more time has to be spent dealing with insurance companies, pharmacy benefit management and other third-party institutions to obtain required medications and get approval for imaging studies and even for the office visits themselves. I have been forced to ration time with her.
This has become a defining aspect in the practice of medicine today. Medicine is a business with significant fixed and ever-rising expenses, coupled with fixed and rarely rising insurance payments. More and more time is allocated to obtaining prior authorizations for tests, imaging, and procedures, justifying our medical decisions, and fighting insurance company and pharmacy benefits denials. By detracting from the time we have to spend with our patients, these administrative tasks can decrease our overall knowledge of them and can have a significant impact on the satisfaction both patient and physician get from their relationship. A physician who chooses to continue to practice as he or she did years ago finds that he or she has very little “away” time, time outside of the practice setting, time to spend with family and personal relationships. This, too, can cause the physician great anxiety and dissatisfaction.
My need to ration time with patients has forced me to make several changes. All patient encounters occur in the examination room only. It reduces the time spent moving from room to room and therefore the overall appointment time, but patients are denied the comfort and sense of ownership that sitting in my consultation room engenders. While I attempt to spend as much time with patients as needed, there is always a strong urge to move on to the next patient. Most of the time, however, I find myself working longer hours rather than deny patients needed access to care. Due to the amount of time it takes to obtain prior authorizations, I rely on my patients to take the lead in these endeavors, further imposing time limits on direct and indirect patient care. Lastly, it has forced me increasingly to consider early retirement or restriction of practice activities as the level of satisfaction with my professional life wanes.
I, like most of my colleagues, love practicing medicine but detest the myriad extraneous, nonessential busywork tasks forced on us by the insurance industry, government regulations, and patient expectations. I often reflect on the fact that, despite the high level of dissatisfaction, anxiety, and depression in the medical community, we continue to deliver the best care in the world. I fervently hope that future generations of physicians will have a greater satisfaction in their work and will not be forced to further ration their time in pursuing this most noble profession.