Time

I am probably an old fogey and given to ranting on occasion, but something has happened to the practice of medicine that makes me reluctant to admit that I am a doctor to those who do not already know. I have been out of clinical practice for a few years and so I have been insulated from the increasing difficulties that colleagues face in trying to practise medicine. It was hard enough a few years ago to cope with ever-increasing overhead and static fees, cutbacks, bed closures, and ever-expanding waiting lists. Nowadays it must be hell out there, but friends’ and acquaintances’ stories of their experiences as patients make me wince.

It used to be that practising medicine was interesting and, in a way, fun. One would get to know patients as individuals, know what had happened to them in the past and what they hoped for in the future. One would know about their families and their work. It seems to have all changed. No longer is a full history taken and physical examination is a rarity—even examination of the offending part. It seems that the style of practice now is “tell-me-your-symptom-and-take-this-pill,” if I am to believe the tales that friends tell me. The rapid, no-touch visit is not a phenomenon confined to family physicians; specialists do it too.

How did this happen? How did the practice of medicine become a dreary and boring, yet harried occupation? I think that somehow the fee-for-service system pays for the wrong thing. We should be asking to be paid for time. I do not know exactly how that could be done, since the physician is paid by an uninvolved third party, but lawyers seem to manage their system very well. If the physician was paid for time spent, he or she would have time to practise clinical skills and make clinical diagnoses, instead of ordering a battery of tests and hoping an answer pops up. I know we have wonderful diagnostic technology now, even if it is not as up-to-date and plentiful as it should be, but a random scatter of tests is no replacement for clinical skill, reasoning, and judgment. We used to be taught that after taking a proper history and performing a comprehensive physical examination that we would have a reasonable diagnosis in mind that would likely be confirmed by testing. If not, then we had either missed a clue or omitted something in our procedure. Medicine practised that way is a very satisfying occupation, and very satisfying for patients who feel listened and attended to and understood.

In contrast, the patient whose doctor allows 3 minutes per patient and who always seems to be hurried and impatient leaves the office feeling dissatisfied, disgruntled, and uneasy. These feelings are reinforced if the patient sees a notice in the office saying “only one problem per visit please” or is told “I don’t accept new patients over 60 years old—they take too long.”

Am I alone in thinking that somehow we have to get the message across that we need more time, time to practise properly so that we can be proud of our profession again?

—PMR