番茄社区

Imagine, if you could, a life without barriers -- well, if not a life, then maybe just perhaps one day. Or the day-to-day.

Every day as we attempt the incredibly challenging task of taking care of people under the modern healthcare system, we are faced with barrier after barrier, some put up systemically, some put up by ourselves, some put up for reasons we cannot even fathom. So many we've let happen to our patients, let happen to our profession, let happen to our trying to take care of people seeking our help and guidance.

Throughout the course of the day, things large and small rise up and try to slow us down on our journey to get our patients as healthy as possible. They come in so many forms (and with so many forms!), and this added burden has been contributing to the incredible sense of frustration and burnout among those of us who are trying to work within the system.

There are enormous barriers that are going to take huge societal shifts for us to help overcome -- critical issues like healthcare inequity and injustice, separate and unequal access to healthcare, and entrenched attitudes of distrust and misinformation that have built up within the communities we are trying to take care of. And there are the smaller things, the day-to-day things, small stumbling blocks that try to trip us up and slow us down, the pebbles that get in our shoe and make the path we're trying to walk more painful than it should be.

For instance, something as simple as trying to get an imaging test for our patients. How did we let this become so complicated? Or prescribing a medication for a patient. When did we turn over the reins of making decisions about this to someone else? Or just using our electronic health record to order healthcare maintenance tasks for our patients. How did we make this a chore that makes us pull our hair out?

Thinking about all of this stuff, we have all, either directly or indirectly, been partly responsible for letting these systems evolve and persist. For example, at some point, somebody said, "If you want to order a CT scan on your patient, under these certain circumstances, you have to go through their insurance company and get prior authorization, and it's in somebody's interest to say no to this request."

How did we as a profession accept this? Who was sitting in on that committee meeting that fateful day when someone said, "You know, these doctors are ordering a lot of CT scans; let's restrict it and let us decide whether they're allowed to order one or not"? Certainly not me, and not anybody I know...

I realize we have to have a system that prevents fraud, that prevents ordering brain MRIs on everybody who has a headache or ordering tests that we know (we've learned?) aren't really going to change management. But we've all spent countless hours beating our heads against the wall of bureaucracy that starts at "No," and does everything it can to keep us there.

When I select a medication for my patient to take, why is that not enough? I have already started getting those end-of-the-year letters from insurance companies telling me about changes to their formularies, what they will pay for or allow us to prescribe. My patient was perfectly fine on medication A, and now they have to change to (relatively equivalent) medication B?

Somewhere, somehow, somebody at some company has figured out how to make a few more pennies, a few more dollars, a few more millions, on one medication over another, under the new contract they negotiated for the coming year. Wouldn't it be better if they all cost the same, so it didn't matter which version of drug X or drug Y that I choose?

And why, when I try to order a routine mammogram for my patient, does this have to be so much work, the clicking of all the boxes in the electronic health record, the reason for the test, the approval from the insurance company, the letters back and forth? They need a mammogram, I want them to have one -- boom, done.

I can think of no other profession that has allowed this much control over the very basics, the nuts and bolts, the day-to-day tools we all use and need to do our jobs, to be taken away from us and put into the hands of some other folks, who have interests other than our own and those of our patients as their first priority.

Although we do need to work to overcome the larger hurdles -- the barriers that have led to inequities in healthcare that are the shame of this nation -- if this current generation of healthcare providers is going to survive and continue to fight the good fight, we also need to figure out how to make the small stuff not so sweaty.

Taking care of people is hard enough. We invest our hearts and our souls and our blood and our sweat and our tears; we sacrifice time with our families and often so much more. It's time we take back control, that we stand up and say, "We're not really sure how this all started and how we so willingly relinquished this control, but the time has come to say enough is enough."

I bet each and every one of you reading this can think of a list of things that slow you down, that just don't make sense, that prevent you from doing the best you can to take care of your patients. Let me know what they are, and let's explore together ways that we can dismantle this system, and make it once again a place we can be proud of working in.

Let's knock down some walls.

, of Weill Cornell Internal Medicine Associates and weekly blogger for 番茄社区, follows what's going on in the world of primary care medicine from the perspective of his own practice.

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