BARRY ROTMAN, M.D., From the health care community
“Doctors must have enough time to listen well”
Contra Costa Times
Article Launched: 11/17/2007 03:06:05 AM PST
AFTER ALMOST 10 years as an internal medicine doctor in a group practice, I quit.
Why? I love treating patients. But our health care system is broken.
Over 7 million Californians lack health insurance. Gov. Schwarzenegger’s universal health care plan, while technically challenging, is a commendable step.
Even if it succeeds in helping the estimated 20 percent of Californians without insurance, there’s still a need to preserve quality health care for the other 80 percent.
As an internal medicine doctor, time is my most valuable resource. Illness is not an isolated biological entity, but rather a disturbance that’s interwoven into the fabric of a person’s life. By carefully listening to patients, patterns and clues emerge.
In evaluating a patient for migraine headaches, for example, I may connect a complicated chain of events that begins with the loss of a family member, and leads to depression and weight gain, which in turn triggers a sleep disorder that sparks migraines.
No MRI or CT scan can replace listening to patients.
Time also goes hand-in-hand with appropriate treatment. The current ethical standards emphasize shared decision-making regarding medical, surgical and end-of-life preferences.
Before a patient chooses to undergo surgery, start a potentially dangerous medication or reject life-prolonging technology, I’m ethically bound to conduct a detailed, unhurried discussion with that individual.
Many factors conspire to worsen time pressure for internal medicine and other primary-care physicians. First, time spent listening to patients, examining them or weighing treatment options is reimbursed at a lower rate than performing a procedure or reading an X-ray.
Second, our reimbursement system favors treating episodes of illness rather than chronic diseases. I’m paid more for fixing a broken pinky than managing diabetes.
Third, medical care grows more complex every year. Patients on average are becoming older. They take more medications, and there are more therapeutic and diagnostic options to consider.
Finally, inflation-adjusted reimbursement has declined for primary-care physicians over the last decade.
Medicare payments to doctors have increasingly lagged behind the inflation rate at the same time that consolidation in the health insurance industry has driven down reimbursement rates.
Many policyholders staggering under the astronomical rise in insurance premiums may not realize that their primary-care doctor receives only a dwindling share of the proceeds.
My peers perform admirably amid this crisis. They maintain the highest professional standards, and struggle to overcome time pressure despite the burgeoning bureaucratic burden they face.
I’m starting my own practice to reclaim the benefits of spending time with patients. My practice will require a retainer fee, an annual surcharge that allows a personalized level of care that only a small practice with a limited number of patients can deliver.
Let me be clear: I am not proud of this financial model. It is not a solution to our national health care crisis. It fails ethical standards of equitable division of resources.
However, I can no longer practice in a system that limits my full potential as a physician and degrades patient care.
Patients want more from their physicians. Many physicians want to offer more for their patients.
Retainer-based medicine is one method to bridge this gap, at least until more sweeping health-care reform addresses the structural limitations that continue to erode the patient-physician relationship.
Rotman is a Walnut Creek physician.