The chief difficulty Alice found at first was in managing her flamingo: she succeeded in getting its body tucked away, comfortably enough, under her arm, with its legs hanging down, but generally, just as she had got its neck nicely straightened out, and was going to give the hedgehog a blow with its head, it would twist itself round and look up in her face, with such a puzzled expression that she could not help bursting out laughing: and when she had got its head down, and was going to begin again, it was very provoking to find that the hedgehog had unrolled itself, and was in the act of crawling away…. Alice soon came to the conclusion that it was a very difficult game indeed.
~Lewis Carroll from Alice in Wonderland
Navigating the U.S. health care system these days reminds me of Alice’s dreamscape game of Wonderland croquet. A physician is given a flamingo mallet and a hedgehog ball and ordered — by the Queen at the risk of having one’s head lopped off — to go play, but the mallet won’t cooperate and the ball keeps unrolling itself and crawling away.
Just like any day in a medical clinic, a doctor’s time is spent trying to manage a flamingo and the patient gets tired of waiting, so gets up and leaves. At least Alice gets a good giggle out of it, but the reality in health care causes more tears than laughter. We are playing a very difficult game of changing rules and uncooperative equipment.
The flamingo in the doctor’s hands represents any of the dozens of regulatory requirements faced daily in the practice of medicine:
- The time-consuming requirement to search over 68,000 ICD-10 diagnosis codes rather than the previous 14,000 ICD-9 codes.
- The requirement to search for a 10 digit NDC number for any prescription medicine sent electronically to a pharmacy.
- The “meaningful use” criteria that regulate mandatory data collection and reportage on patients to the Federal Government in order to receive full payment for Medicare or Medicaid billings.
- The expansive HIPAA and HITECH electronic security requirements to ensure privacy.
- The obligations for increased “productivity” that your employer monitors.
- The disputed Maintenance of Certification (MOC) hoops to jump through in order to continue to practice medicine.
The exasperated and uncooperative “managed” flamingo keeps curling itself around and looking at us with a puzzled expression: Just what is it you were supposed to be trained to do? Is there actually a patient to pay attention to in all this morass of mandates?
And the poor hapless hedgehog patient is just rolled up in a ball waiting for the blow that never comes, for something, anything that might look like health care is about to happen.
Instead there are unread “Notices of Patient Privacy” forms to sign, the “Patient’s Rights” document to review, as well as releases to share medical information to sign, agreements to pay today’s co-pay and tomorrow’s deductible and whatever is left unpaid by Affordable Care Act insurance, passwords to choose for patient portals, insurance portals, lab portals and healthcare.gov. It might be easier and less painful to just crawl away and hide from that bumbling physician who can’t seem to get her act together.
I wish I were laughing about the “game,” but I’m not. As both a physician and patient, it’s getting harder and harder to play the game that is no game at all. The threat of losing credentialing in an insurance plan, or getting poor ratings on anonymous online physician grading sites, or being inexplicably dropped from a provider list, or too unproductive to remain in an employer medical group, or losing/foregoing board certification is like a professional beheading.
“Off with her head!” indeed.
We keep trying to juggle the flamingo motivated by those threats, all the while ineptly managing the managed care system, and hoping the patient won’t walk away out of sheer frustration.
It’s hard to remember why I’m in the game at all. I think, at least I hope, I wanted to take care of people, heal their illnesses and help them cope with life if they can’t be healed. I wanted to provide compassionate care.
It is enough to make a doctor cry. At least we can meet our patients at the Kleenex box and compare notes, and maybe, just maybe, we’ll be able to play a round or two of croquet.
Dr. Emily Gibson is a family physician, farmer, poet, wife, mother and grandmother. She has worked in inner city primary care, community and rural health, detox and sexual assault centers, and as the medical director of a University Student Health Center for three decades. Both a photographer and writer, she shares daily about her life and work on her Barnstorming blog.
Dr. Gibson is a 2018–2019 Doximity Author.