It’s a broken system. Practicing here in Rhode Island and the east coast reminds me how broken health care is. Perhaps it’s the east coast specialist mindset, but many patients have several specialists that they see, are used to annual exams with a boat-load of labs, and many women have a gynecologist and are surprised that family medicine can take care of their “female” concerns. A colleague told me that she thinks family medicine salaries are low compared to other regions because patients consume so much health care and the family medicine skill set spectrum is forced to be narrow, at least in urban mid/upper income areas. Another colleague remarked that if you need a specialist for every two organs, of course health care costs are exorbitant. Check out heath care expenditures by state.

Access is tough too. As a new provider in a state where primary care docs are limited I am seeing patients who have been on waiting lists for 6-8 months. One patient called 35 offices to find a primary care doc taking new patients. I dutifully studied the United Health Care web site for primary care providers taking new patients. I called 10 offices who were listed as taking new patients only to be told they weren’t and finally pulled strings to get seen later this month so I can get a proper refill of blood pressure medicine. I’ve been refilling my own for the last year since we’ve been on the road. Many of the patients I’m seeing have been in long-term relationships with their family doctor and are leaving because the insurance company is no longer contracting with physicians who are not in a group practice. I’m nice enough, but they’d prefer to see the MD they’ve seen for the past ten to thirty years, thank you very much.

Some patients are doctor-shoppers who are hoping I might agree to fill their controlled substance medications: ADHD medications, or the valium-family of medications, or pain medications—those opioids we’re hearing so much about these days. I checked the old records of one new patient to confirm her ADHD diagnosis, then agreed to fill her meds after she gave us a urine and signed a contract. When the urine showed cocaine that ended my willingness. She was apologetic.

Other patients are difficult patients, the kind with lots of requests who wear out their physician and clinic. Yet others have slipped through the cracks, because they don’t follow through with what they need to do.

Portability state to state is tough too. Reed purchased COBRA to cover his health care needs when he left his Ohio job. He has faced no in-network providers here, that means out of network costs and he’s already paying $600/month for health insurance!

On the doctoring end, it isn’t much easier. Now, I am learning yet another electronic health record (EHR), Epic which I’ve used before. But as they say if you’ve seen one EHR—you’ve seen one EHR. Historically I’ve liked Epic, but this version is clunky with lots of work arounds that are not intuitive. Most likely the health system purchased the Chevy, not the Cadillac. Regrettably, it seems that I spend more time studying the computer than looking at my patient. And patients expect me to have access to their old records. Sometimes I do, but more often I don’t. That means the old fashion requesting paper print outs of computer records and wading through paper piles before scanning them into our EHR.

So today I read that Atul Gwande, surgeon, will be running a new venture put together by CEOs of Amazon, JPMorgan and Berkshire Hathaway. Hurray for Atul, I’ve been a fan of his New Yorker essays as well as his books. I’m not sure one creative thinker can do it, but we need to do something. Right now insurance drives the system and it is not patient centered. And as a doc, it’s not much fun paddling through the clicks and papers to get the patient what he/she needs.