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The Doctor Knows Best


The growing list of payer demands continues to drive medical decision making. It can also impede patient care and hasten physician burnout.

Are you burned out? How would you know? In recent months, I've read a number of articles and reports about physician burnout. Multiple factors contribute: Excessive clerical duties, the EHR, and a loss of autonomy tend to be the most prevalently cited frustrations. As we move toward a higher-quality, more efficient, increasingly electronic way of providing care, the spotlight has shone brighter on physicians. Adding to this is the increased emphasis on cost containment, and patients who demand more complex answers to questions and desire more out-of-office contact with physicians. While patient-centered care is important, the physician cannot be lost in the equation.

In January, I started to see more denials for a topical anesthetic patch I commonly prescribe for neuropathic pain. I was surprised at the onslaught of non-formulary letters I received. What made the situation particularly frustrating is that I had to respond individually to each separate request and that there were no viable alternatives, as these patients were already using the "formulary" medications without sufficient benefit. In the past few months, I've had to write a mini-evidence-based review in an appeal letter to an insurance company in order to get an imaging study covered, trial inferior medications in order to prove that my patient actually needed what I'd already prescribed, and deal with requests from insurers to enter all kinds of data into their own systems for small amounts of reimbursement.

The final straw came recently when I was going through a 15-page online form summarizing the preventive care I provided to a patient. It asked whether the patient had depression. I checked the box marked "no." Then it asked for the patient's PHQ 9 score. I tried to click past it as I had not administered a depression screening questionnaire to a patient who denied symptoms of depression. No luck. The form would not let me move on to the next page until I gave a numerical score. So, I quit out of it, abandoning the time I'd already spent.

These are all small frustrations, none overwhelming in themselves. However, they contribute to the growing list of demands, rules, requirements, requests, and regulations that govern multiple aspects of the care we provide. As medicine is getting technically more complex, as there are more clinical guidelines - some conflicting with each other - to review, and as patients get increasingly savvy and discerning about their care, the burden on physicians begins to feel insurmountable. This is occurring against the backdrop of a rapidly changing healthcare system.

What are we, as physicians, supposed to do? Certainly, abandoning ship is an appealing option at times, and physicians are choosing non-clinical careers, retiring early, or reducing time in patient care. Avoidance and denial are becoming more difficult to do as healthcare reform spreads. However, none of these avenues, used as means to avoid the frustrations and grievances that contribute to burnout, work in the long run.

Instead, physicians need to stay in the conversation and shape the debate. We need to define what it means to be a physician in this new era of healthcare and continue to demand that the work we do is valued, even if the cognitive work we do is not provided while we are looking in a patient's eyeballs. We should encourage our patients to join us and recreate the physician-patient relationship.

Having autonomy is an important way to burnout-proof your career. Autonomy is not necessarily something that is handed to you or afforded to you. Physicians will increasingly need to create, demand, and seize autonomy over those aspects of medical practice that most clearly impact us and the care we provide.

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