Indulge me while I vent about a major frustration of mine - a frustration born out of inefficiencies and bureaucracy.

Several weeks ago I had a patient who was acutely ill and needed a specialist. I started the patient on medication and called the specialist that day. I was able to speak only to the receptionist and finally a nurse. I filled the nurse in on the situation and faxed all of my records to the office. I never got a call back from the physician. The patient was scheduled to be seen 3 weeks later. For three weeks I saw the patient twice weekly, checked-in on her over the phone, titrated medications, sent updates to the specialist’s office, called the nurse again (leaving a voicemail that was never returned), and sent labs and imaging study results to the specialist’s office. I filled out forms for time off work for the patient. I filled out prior authorization forms for her insurance company to allow her to have the tests she very obviously needed. I spoke with the patient’s family members (with consent) so they could help manage this patient’s complex and high risk problem.

3 weeks went by and the patient was finally able to see the specialist. The patient called me that day telling me what the specialist had said. Some of it made sense. Some of it needed clarification. I called the office. I was put on hold. I was sent to a dead end voicemail. I finally left a message for the nurse. I then called again later in the day because my patient needed quick input. I asked for medical records (if I couldn’t speak to the doctor, could I at least have the consult note?), and I was told that I could not have the notes unless the patient I had referred there signed a release. This is absolutely not true, but I was unable to convince anyone in the office of this fact. With no other choice my staff managed to get a consent signed by the patient and faxed the release. We called again. We finally got a copy of the consult note.

I never got a call back from this specialist. Apparentlhy the office had never received any of my notes or labs. How that is possible I do not know. Faxes are an inherently imperfect platform of communication, but I did get confirmation on the faxes and the numbers were correct. Why, with all those calls and contacts with this office, had no one bothered to tell me that they did not receive records? Why couldn’t the specialist spend 5 minutes to call me and hear the information I had gleaned over the previous 3 weeks? I will never know because I never received a call back. I am still working to get the advanced studies authorized because the insurance inexplicably denied it.

As a side note I could have side stepped ALL of this bureaucracy had I just sent the patient to the ER. Poof immediate access to all the labs and images we could ever want with out a prior authorization, immediate access to a specialist via telemedicine without the wait. No time on my part, and in this case no additional expense to this medicaid patient. As we all know, that does not mean no additional expense, and while I discussed this option with the patient, she was against it.

10 years ago, not getting a call back from a colleague was absolutely unheard of. Even if a doctor had to call me late into the evening after a long day he or she never left the call unanswered. About 4 years ago I had my first non-returned call. A cardiac nurse practitioner had her nurse call me back. I was shocked. The nurse did not have the training to answer my inquiries. I pushed until I was able to speak with the provider. I was dismayed, and I thought maybe it was a symbol of a new generation of providers who did not have the same training and integrity. Or was it? Last year I had a neurologist in Spokane see a patient of mine, charge her $200 then never send me a consult note. I called and faxed requests and called again. What I finally got was a note WITHOUT A PLAN. The data was there, but there was no diagnosis, and NO PLAN. I called, my medical records dept called, my office manager called. The doctor never called back. To this day, I have no idea what his plan was, nor did my non-english speaking patient. She waited months for the appointment, drove 2 hours, sat in an office for another 2 then drove home for nothing. And she was charged for it. I can list many anecdotes like this as they are becoming more and more commonplace. It is a new norm, and it sucks.

This is what drives me so crazy about all of this. A simple physician to physician phone call is so often all that is needed to care for someone. A five minute call can save hours of patient, physician and nursing time and avoid unnecessary tests and confusion, but our system does not reimburse for phone calls, so they are getting squeezed out. To make matters worse, primary care doctors and specialists alike are moving about more than ever, and it can be difficult even to know who is in a given office at a given time.

What is the answer? Does the doc work the extra 20% without reimbursement, knowing that they can charge $200 to answer the same question face to face with the patient? Does the insurance company find a way to reimburse based on outcomes? Medicare is trying that. There are performance measures in place, but so far none have been shown to improve outcomes. The money received from these programs goes right back into funding the tracking and extra personnel required to document the outcome measures. The cycle continues.

For my part, I am willing to work for less money for the sake of better outcomes and better job satisfaction, but primary care salaries are already dwindling and many providers are already opting for other options outside the clinic. Do we really want to deter people from going into this already difficult profession by cutting their salaries? I am hopeful about working with remote physician platforms that allow physician to physician consults for simple consultations that don’t require an hour long patient-physician visit. In Washington we have publicly funded psychiatry telemedicine consultations and it works wonderfully. There are also some options for women’s health consults and a program through OHSU in the works for dermatology. There are likely others I am not aware of. RubiconMD is the platform I plan to use when my patient volume warrants it. Would I rather call my local dermatologist for quick input on a suspicious mole? Unequivocally, yes, but not if they won’t call me back.