Out of Practice: Fighting for Primary Care Medicine in America

By Frederick M. Barken

Primary care medicine, as we know and remember it, is in crisis. While policymakers, government administrators, and the health insurance industry pay lip service to the personal relationship between physician and patient, dissatisfaction and disaffection run rampant among primary care doctors, and medical students steer clear in order to pursue more lucrative specialties. Patients feel helpless, well aware that they are losing a valued close connection as health care steadily becomes more transactional than relational. The thin-margin efficiency, rapid pace, and high volume demanded by the new health care economics do not work for primary care, an inherently slower, more personal, and uniquely tailored service.

In Out of Practice, Dr. Frederick Barken juxtaposes his personal experience with the latest research on the transformations in the medical field. He offers a cool critique of the "market model of medicine" while vividly illustrating how the seemingly inexorable trend toward specialization in the last few decades has shifted emphasis away from what was once the foundation of medical practice. Dr. Barken addresses the complexities of modern practice—overuse of diagnostic studies, fragmentation of care, increasing reliance on an array of prescription drugs, and the practice of defensive medicine. He shows how changes in medicine, the family, and society have left physicians to deal with a wide range of geriatric issues, from limited mobility to dementia, that are not addressed by health care policy and are not entirely amenable to a physician’s prescription. Indeed, Dr. Barken contends, the very survival of primary care is in jeopardy at a time when its practitioners are needed more than ever.

Illustrated with case studies gleaned from more than twenty years in private practice and data from a wide range of sources, Out of Practice is more than a jeremiad about a broken system. Throughout, Dr. Barken offers cogent suggestions for policymakers and practitioners alike, making clear that as valuable as the latest drug or medical device may be, a successful health care system depends just as much on the doctor-patient relationship embodied by primary care medicine.

• Language: English
• Publisher: ILR Press
• Release date: Apr 15, 2011
• ISBN: 9780801461088

Book preview

OUT OF

PRACTICE

FIGHTING FOR PRIMARY CARE

MEDICINE IN AMERICA

Frederick M. Barken, MD

ILR PRESS

AN IMPRINT OF

CORNELL UNIVERSITY PRESS

ITHACA AND LONDON

In memory of my

mother and father,

Norma and

Herbert Barken

CONTENTS

Acknowledgments

Introduction: The Doctor Is Out

1 A First Visit with the Doctor

2 Tell Him Not to Drive

3 Polypharmacy: The Problem with Pills

4 Poly-Doctoring: A Doctor for Every Disease

5 A Bubble Off

6 On the Road Again

7 The Supply Side

8 All in the Family

9 Practice/Malpractice

10 You Get What You Pay For

Epilogue

Notes

References

ACKNOWLEDGMENTS

For most of my adult life, busily spent practicing primary care medicine, I wrote nothing longer than a prescription. The prospect of a sustained project involving uninterrupted research, writing, and reflection seemed an appealing personal indulgence, but also a daunting challenge of organization and discipline, resisting the chaos and attention deficit of daily life. Luckily, I had help.

I am most grateful for the sage advice and unwavering encouragement I received from my friend Richard Polenberg, professor of history at Cornell University, to whom I first proposed the premise for this book three years ago. His kind words, support, and thoughtful commentary correctly anticipated the unavoidable wrong turns and dead ends inherent in writing. They were medicinal.

I wish to give special thanks to David Williams, professor of theater at the Ohio State University at Newark, who volunteered to review and critique my writing, gently tweaking my grammar with his powerful pedagogical red pen. I have the greatest respect for Dave’s high regard of literature, theater, and the elegance of the well-turned phrase. Narrowly trained in the sciences, I admire his love for, and life in, the arts.

The writer’s life, I feared, was one of solitude; I could not have been more wrong. I am fortunate to have a group of friends and colleagues, all from diverse fields and life experiences, each with a personal perspective on the matter of health care. It seems as long as I continue to write about the plight of the physician-patient relationship, I will never be lonely. Dave Ahlers, Lorraine Anastasio, David Bick, Tim Cardina, Mitchell Greenberg, Bruce Korf, David R. Lee, and Chris Ober provided challenging critiques and engaging commentary as they graciously devoted their time to reviewing this book cover to cover. I appreciate, as well, the thoughtful reviews of some of the early chapters by Ed Gasteiger and Tony Votaw. With each review came another story, a personal anecdote of a health care encounter gone awry, that confirmed the universality of my subject and the unbounded demand for high-quality primary care. In that, none of us is alone.

At the start of my medical career, I was blessed to find and work with Ginny Jones, my first office nurse, secretary, and personal guide to the practical operations of primary care, and to the sometimes whacky world of private practice. In many ways, mine was often the second opinion. She, along with Karen Cotterill, maintained a high level of clinical professionalism with feeling, in these most challenging times for the practice of medicine. Judy van Coetsem, my one-person billing department, fought a valiant but frustratingly lopsided fight against passive-aggressive health insurers. I thank each of my key employees for their years of service and dedication to patient care. By the same token, I thank the many thousands of patients who I have seen in my office over the years, all of whom entrusted me with their precious health and private worries. In the new world of corporate care, it is so easy to forget that the practice of medicine is a privilege, granted by patients.

I am grateful for the medical library services provided by the Cayuga Medical Center in Ithaca, New York, and I specifically thank Ward Romer, the hospital librarian, for his dedicated and sustained services in the acquisition of seemingly endless references. Susan Enkelmeyer, former dean of the School of Business at Ithaca College, graciously provided me with the use of a vacant office, a quiet and welcome change of scenery. Graham Sterling, while a senior studying gerontology at Ithaca College, did some of the preliminary research on physician home visits. Jennifer Carr and Stewart McGough of the law firm Scolaro, Shulman, Cohen, Fetter, and Burstein, P. C. kindly provided me with anonymous samples of a malpractice summons and complaint. Paige Davis did an early stage edit of the manuscript and Karen Hwa and Katy Meigs brought the editing and formatting process to a successful conclusion. I am most grateful to Ange Romeo-Hall, Senior Manuscript Editor at Cornell University Press, for her instruction and assistance in the editing process. From my first contact with Cornell University Press, I have received nothing but support and affirmation, plus constructive guidance. Suzanne Gordon, co-editor of the Culture and Politics of Health Care Work series, shepherded me through the process, chapter by chapter, helping me formulate and focus my message. I thank her for her collaboration and commend her for her passionate commitment to improving primary care in America. I am grateful, as well, to Mahinder Kingra, Nathan Gemignani, Jonathan Hall, Susan Barnett, Katherine Liu, Fran Benson, and John Ackerman of the Press for their emphatic support.

Foremost to thank, however, it is my wife, Marlene, who helped make this book a reality. A consummate teacher and a congenital optimist, she helped me to channel the frustrations of my field into a contemplative career retrospective. More than providing an in-house first edit and tolerating my commandeering of the dining room table and scattering it with papers so that it resembled the aftermath of a tornado, she helped me see the big picture.

Each generation in America wishes better for their children. My wish is that my own children, Joanne, Jeffrey, Stephanie, and David, now all young adults, will enjoy good health that is enhanced by ready access to quality primary care and the salutary benefits of a solid physician-patient relationship. If this book contributes to that goal, it will have been a personal success.

FREDERICK M. BARKEN, MD

Ithaca, New York

INTRODUCTION

THE DOCTOR IS OUT

On June 30, 2007, at the relatively young age of fifty-one, I left the practice of medicine. After nearly a quarter of a century spent building and managing a busy, locally well respected and successful private practice in primary care, I chucked it all and walked away from my professional career. Was I the victim of burnout, a vague but insidious ailment common to busy older physicians that renders them indifferent and inured to patients’ problems and pains? I don’t think so. Rather, it was a resignation. In chess, after a wearying and protracted battle, there comes a moment, shortly before checkmate, when one player realizes that all is lost. Moves and countermoves are exhausted; the contest has played out. The time had come for me to leave primary care, to vote with my feet, and to find personal and professional happiness elsewhere. I chose to resign from the practice of internal medicine ten to fifteen years earlier than is usual, but still with dignity, as I saw the quality and personal satisfaction of primary care medicine eroding. I had lost the match.

Who was my opponent in this metaphorical losing game of chess? I could trot out the common cast of characters so often cursed and vilified in hospital doctors’ lounges, at medical meetings, or wherever two or more physicians convene: the evil insurance industry, the bean-counting bureaucrats at Medicare and Medicaid, or the malevolent malpractice plaintiffs’ attorneys. Certainly, they all had done their part to erode the rock-solid footing of my practice. Rather than round up the usual suspects, however, I now reflect that, as a solo practitioner of primary care, I have lived through a slow but tectonic change in American health care delivery, a paradigm shift.

I was a premed student during the 1970s, a time when people still could remember house calls made by their family physician, a pillar of the community, a Norman Rockwell American icon. For the Boomers, the first generation raised on TV, there was Marcus Welby, the avuncular family doctor, an ever-available friend and personal physician to only one patient per weekly episode, who had not yet gone on to syndicated reruns. Times change, however, and so did primary care. By the mid-1980s, when I had completed my internal medicine residency and was busy building my practice, the government and private insurers had begun a concerted effort to contain the escalating cost of health care by fiat. The kindly family doctor was diminished, downgraded, and deprofessionalized to the status of a provider, a bland descriptor on a clerk’s requisition form. Even worse, New York state’s Medicaid, which insured the indigent, classified me as a vendor, a term that sent me into orbit then and that still rankles today. Hemmed in by profession-specific price controls, reams of restrictive regulations, heavy-handed threats of federal penalties and expulsion from Medicare for suspected infractions, I became disheartened. My patients, however, still held the traditional view of their doctor as a knowledgeable authority and a personal source of comfort, advice, and strength. They did not know that the supportive scaffold, their primary care physician’s practice, already had developed dry rot.

The years went by and, disregarding exaggerated reports of my profession’s demise, I busily continued to see patients and to practice medicine as I thought best, with a personal touch, a close connection, and a physician-patient relationship best delivered by a solo practitioner in a small office. In the early 1990s, managed care and health maintenance organizations (HMOs) arrived on the scene. As a primary care physician, I was recast as a gatekeeper, the person at the turnstile of a veritable health care amusement park where those with a ticket (a valid health insurance card) could spend an afternoon with a specialist, take a ride in the magnetic resonance imaging (MRI) scanner, or visit the X-ray funhouse.

What’s in a name? Whether I was termed a gatekeeper, a provider, or even a vendor, I was where I wanted to be, still practicing primary care medicine in a very traditional way. I cultivated satisfying relationships with several thousand patients and their families, each unique, and I felt rewarded in providing an essential service for my community. Although the bureaucracy and banditry of the health insurance industry was a slowly constricting circle that annoyed as it encroached, in the mid-1990s and even early in the first decade of the twenty-first century, I still could ply my craft.

Time passed. My patients grew older. They probably thought the same about me, but they had grown much older. Elderly women, beneficiaries of an elongated lifespan, continued to come see me. Even men in their nineties paid me regular visits. Mirroring a national phenomenon, a trend toward the geriatric, my practice increasingly was composed of the fragile, chronically ill sufferers of multiple degenerative diseases, all laden with the psychosocial complexities of the first superannuated add-on generation in human history. It seemed they were all there, sitting in my waiting room. Medicare apparatchiks and federal budgeteers, the bill payers, probably thought so as well.

Now, in 2011, the dark cloud of Medicare insolvency hangs on the horizon, saturated with the heavy burden of 78 million nearly geriatric Baby Boomers. My quite traditional small solo private practice, so twentieth-century in concept, is no longer viable in a modern Walmart-style business environment of everyday low prices and paper-thin profit margins. Few primary care physicians today are able to meet the extraordinarily large volume of care demanded by the soon-to-be-senescent Woodstock generation. Something must give.

Enter the Harvard Business School. Their mission: to apply their analytic powers to a challenging market problem, examine a service or product and its users, and tweak a business to achieve greater efficiency and productivity, thereby greasing the wheels of commerce. The practice of medicine, in theory, should be no less amenable to analysis than any other business. Harvard’s Clayton Christensen offers The Innovator’s Prescription: A Disruptive Solution for Health Care, his vision of a brave new world of doctoring in the twenty-first century (Christensen 2009). He sees my office as a solution shop, a quaint but outmoded and anachronistic storefront akin to a small Main Street hardware store or the premises of a butcher, baker, or candlestick maker. According to Christensen, mine is the last great cottage industry in the United States.

Christensen proffers a model of medicine in which the functions of a physician are teased out, stratified, and supplied in bulk by technically optimized deliverers of narrow and specific services. (For example, a hernia is repaired in a hernia center.) Care is commoditized. The wholesale liquidation of traditional holistic primary care, however, recapitulates the creative packaging and repackaging of mortgage products, credit default swaps, and the clever stripping of securities into tranches (peeled-off profitable portions), which contributed ultimately to the massive financial market meltdown of 2007. As a physician, that is a path I choose not to take.

Primary care, as I knew and enjoyed it, is principal care, relational in its very nature. It is delivered in a continuum, sometimes over decades, often across generations of family members. It is not merely a series of short, staccato transactions, technically correct but emotionally empty and dispensed like fast food. The practice of primary care fundamentally does not lend itself to fractionation or focused factories. Primary care is different; it is a unique health resource and a national asset, but its survival is in serious doubt. I am neither the first nor the last to close up shop. By leaving practice, I lost many delicate, slowly cultivated, and sustained relationships with my patients; such relationships are remarkable phenomena that lie beyond the purview of any conventional business model. Yet, it is I who am now out of business, not the economists at the Harvard Business School. The postmortem on primary care in the United States may well read: Death by Disruption.

To be sure, the practice of medicine is a business. The fruits of my labor as a doctor (along with my wife’s income as a college professor) fed, clothed, and educated our four children, covered the mortgage, and sustained a comfortable and fortunate upper-middle—class standard of living, for which I am grateful. I doubt that future primary care physicians will enjoy the same financial rewards for enduring the rigors of primary medical education, internships and residencies, and the chronically corrosive strains of modern practice.

Peter Orszag, the initial director of the Office of Management and Budget under President Obama, admonishes Americans that we are in financial trouble today because each of us consumes too much health care, as though it were an ice cream treat. We gorge on a large or extra-large measure of medical care, rather than show some restraint and order a small or medium portion. This tasty dessert analogy superficially seems plausible, given that morbid obesity has recast the shape of modern man. However, it is a specious argument. Rather, it is to the credit of modern medicine in the United States, including good comprehensive primary care, that we now confront the challenge of a senescent society. The United States burns more bucks today on health care because its citizens are older, more fragile, more dependent on a medical infrastructure for their tenuous survival, and in greater need of ready access to good primary care than ever before. The notion that health care for a sick and aging nation somehow can be streamlined and economized (faster, better, and cheaper) is quite naive; we can have any two, but not all three. Primary care, in particular, is inherently inefficient. Because it is relational, good primary care takes time. Complex matters, convoluted family dynamics, and critical health decisions must be addressed in the context of a continuous, supportive, and trusting physician-patient relationship that is the polar opposite of fast food. Robbed of the ability to develop such relationships, many time-pressured, deprofessionalized primary care physicians will choose the route I took: an early exit. Current medical students, future physicians to the Boomers and beyond, have all received the text message gone viral: Stay away from primary care.

In this book I recount my personal experience, not to elicit sympathy or to wallow in nostalgia for some golden age of medicine in which the physician reigned supreme, powerful, and prestigious, as he (not she) snapped orders, prescribed paternalistically, and enjoyed a work environment unencumbered by regulations or quality control. Good riddance to that. I note, however, that also gone is a kinder, gentler form of medical practice that I knew all too briefly when I was much younger and just entering the profession. There was camaraderie among colleagues. We possessed a willingness to stop and recount an interesting case, help solve a diagnostic dilemma, or even share a joke in the admittedly macabre gallows humor of the young physician. The practice of medicine was fun. It was social. It worked.

A physician-patient relationship thrives in a socially rich environment; it withers when market-style interactions supplant the social and care devolves into a pure business transaction metered by the minute (Hartzband and Groopman 2009). Like marriage, primary care is there in sickness and in health. To know my patients well, I must see them in good times and bad, be there for their trivial complaints and their tragic events. Primary care is a package deal, not divisible by degree of profitability.

Primary care medicine is collapsing, a victim of economists’ tenets of maximized efficiency, profit, and productivity. There is no heading on an accountant’s financial statement for altruism, empathy, a warm smile, or other random acts of kindness that we all appreciate as patients and as people. Physician frustration, alienation, and chronic suppressed anger at such a market model of medicine have done us all, physicians and patients alike, immeasurable harm.

Since leaving practice, I have thought long and hard about what went wrong. In the following chapters, I reflect on unfavorable trends in primary care that I personally have witnessed but that are amenable to repair. Consider, for example, polypharmacy, doctors’ propensity to overprescribe, and poly-doctoring, the excessive and expensive referral to multiple specialists. Experience the malaise of a malpractice suit hanging like the Sword of Damocles over the heads of health care professionals. Envision, if you will, the near-future world of 78 million aged Baby Boomers, many suffering some degree of cognitive impairment, demanding high-quality and personal attention from a scant number of primary care physicians. Imagine the frustration of trying to provide effective medical care to an elderly patient who lacks the support and sympathy of a functional, loving, and close-knit family. This is primary care in twenty-first-century America, and we have a very big problem on our hands.

The United States currently is engaged in an uncomfortable soul-searching self-appraisal of its health care system. The problem of millions of people without access to health care, the staggering price tag of modern technologic medicine, and the graying of America are subjects that can no longer be ignored. As a fundamental principle, every American deserves ready access to a compassionate, comprehensive, and sustained relationship with a primary care physician, the backbone of good health care. Models of care have come and gone throughout our history (Starr 1982). The solo private practitioner is one incarnation, which will be replaced by a new and more workable model still in evolution. Regardless of the future format, it is the relationship between a primary care doctor and a patient that must endure for there to be a core of good care. We must stop to appreciate the remarkable and vital, if unconventional, nature of primary care. We need to do it quickly, as though our lives depended on it.

1

A FIRST VISIT WITH

THE DOCTOR

Compassionate, high-quality primary care medicine, both affordable and accessible, is fundamental to U.S. health care. It is the right of every American, and it is a national moral imperative. It is the cornerstone of care and our best defense against the human misery of disease, dysfunction, and frailty. Elections, geopolitical crises, and economic upheavals may come and go, but the essential need for a good primary care doctor is here to stay.

This is not news. Other nations throughout the world, rich and poor, have designed health care systems that prominently feature ready access to effective and efficient primary care (Reid 2009). Their moral commitment is their mission statement. We in the United States, however, are different. We pay lip service to the significance of a strong and sustained relationship between a patient and his or her personal physician. No one should stand between you and your doctor! exhorts a paid political advertisement. Although this is a solid sound bite that packs a powerful punch, it is pure fantasy.

My small examination room, designed for quiet personal consultation, is already crammed with unobserved third parties intruding on an ostensibly very private relationship. Pharmaceutical representatives, those well-dressed young men and women carrying pill samples and wearing corporate logos, are there to persuade me to prescribe their newest and most expensive products. Midlevel managers of health insurance firms and HMOs are also in the room, containing costs by restricting and rationing care through the ploy of prior approval. Medicare bureaucrats are there as well, codifying care of the elderly, translating the art of medicine into volumes of digitized diagnostic reference numbers and procedure codes. Soon the bureaucrats will also be scoring the clinical outcomes of care in an arcane formula for physician reimbursement. Last, the plaintiff’s medical malpractice attorney lurks in the corner, never out of my mind for a moment, as I defend myself daily through ever-escalating diagnostics and unceasing documentation, always producing a well-buffed chart, but not necessarily a healthier, happier patient. Seating is indeed limited in the exam room; patients should be advised that there may be standing room only.

A wide chasm exists between the often-touted, lofty ideal of high-quality compassionate primary care for all Americans and the carborundum-like grind of the daily practice of modern medicine. Lost in the abyss is the essential and unique quality of primary care medicine, a valuable but exhaustible national resource. Consequently, the sustaining and supportive personal relationship between a doctor and a patient over a protracted course through thick and thin is in jeopardy. We should mind the gap.

It is not sufficient, however, merely to offer a paean to primary care, singing its praises without appreciating what it is or how it works. As with the modern laptop computer, the iPhone, or the GPS direction finder, we depend on good primary medical care without knowing what’s inside. We stand to gain from a look under the hood. I invite you, therefore, for an office visit; the doctor will be with you shortly.

Enter my waiting room. It is busy, but not bulging. You sign in at the desk and receive a clipboard, a pen, and a sheaf of insurance forms to complete (the adult equivalent of the issue of Highlights that once kept you occupied as a child waiting in the pediatrician’s office). You take a seat, surreptitiously surveying the status of those who precede you. One is in a wheelchair. Another is gaunt, blighted by malignancy and tethered to an oxygen cylinder. You already feel a little better, relieved at your relative apparent good health. This is not schadenfreude; you are merely whistling past the graveyard. Then you realize, however, that you and these poor sick souls share one thing in common: each is awaiting fifteen minutes of fame, an appointment with the doctor. Judging from the condition of the crowd, this could be a long wait. As in the barber shop, where you count the heads to be shorn before yours, you grab a magazine or two, settle in for the duration, and take a further look around the waiting room.

The doctor’s waiting room decor is a matter of calculated choice. Soft pastels soothe. Carpeting adds warmth and muffles sound for privacy, but it must not snag a shoe and topple an unsteady patient. The chairs are comfortable but firm. Squeezing three patients onto a plush sofa violates everyone’s personal space, raises the fear of contagion, and evokes embarrassment in a frail patient who will not be able to stand up unassisted when the time comes to see the doctor. The office of today is necessarily equipped with a few heavy-duty, extrawide chairs for the morbidly obese, each chair a space-occupying throne rated to hold well over four hundred pounds, dwarfing other Lilliputian conventional furniture. A low-maintenance potted plant, a philodendron or palm, adds a little life through greenery. (Perhaps it is wise to avoid a physician whose office plants look wilted.) A little bland music from overhead rounds out the neutral, if not numbing, ambience of the physician’s waiting room.

The waiting area should be clean, well lit, comfortable, and quiet. It must appear professional, but not showy or opulent, lest patients start to grumble that the doctor is doing too well by their personal misfortune. Patients are natural doctor watchers. They know what car I drive, what shirts and ties I wear, and my taste in office artwork. A new patient begins to form an opinion of her doctor before the front door closes on her way in.

Satisfied with my well-appointed waiting room, you flip through a magazine you have chosen from a broad selection of reading material. There is a well-worn, dog-eared copy of People, a variety of news weeklies, National Geographic, and a potpourri of women’s journals that incongruously juxtapose a photo of a large and luscious slice of cheesecake next to a headline in bold about an amazing new diet. There may be an attention-grabbing exposé explaining how to tell if your doctor is incompetent. That’s a perennial feature I always appreciate. Stale magazines in the doctor’s waiting room are a hackneyed joke. ("Doctor, I see from this copy of Newsweek that President Nixon has resigned.") Complaints about the age, selection, and appropriateness of waiting room reading material, however, illustrate an important aspect of the practice of medicine: it is also a business.

The customer is always right, I am told. We like to think of health care professionals as poised on a higher moral plane, scientifically confronting disease, aggressively ameliorating pain, and selflessly addressing suffering. Yet, physicians are also a profession of shopkeepers, that must address mundane complaints from disgruntled customers. A rather prudish woman in her forties, leafing through a copy of the New Yorker while waiting to be seen, came upon an article announcing the opening of a current photographic exposition in Manhattan. There, as a full-page feature, was a sepia-toned, artistic, and antique black-and-white photo of a naked woman, in my office! The patient complained vehemently to my secretary that the magazine should be removed at once; we did not comply. I recall this story, though, to highlight the bizarre world of private practice, where the doctor wears many hats, including, it seems, that of censor. A patient’s most strident complaints may vary widely from what health policy analysts and lawmakers fret about today: quality of care, access, and cost. The straight-laced puritanical woman rightly should have stood up to complain that everyone seated in my waiting room that day would pay a widely differing fee for professional services rendered, depending on age (Medicare), job (various private health insurance companies), or dire financial straits (Medicaid). That is a fact far more obscene than any risqué photojournalism found in the New Yorker.

How long must I wait? a man asks as he raps his knuckles loudly against the sliding glass window, only inches from my secretary’s ear, laying the foundation for her day-long headache. Straining to maintain a pleasant demeanor, she replies with a friendly Good morning, dodging the man’s pointed question while directing office traffic flow. She invites the man to have a seat, complete his paperwork, and await his 9 a.m. appointment with the doctor. Not an avid reader of People or Popular Mechanics, he strikes up a conversation with the woman sitting next to him. She, he soon discovers, also has an appointment for 9 a.m.! How can this be? He steps up to the window and again raps vigorously against the secretary’s glass enclosure. Her headache, an occupational health hazard, intensifies.

Medical appointment scheduling is both art and science. It is a form of fluid dynamics, regulating the flow of individuals, each moving at a different rate and presenting different needs. There is surprisingly little correlation between the severity of an illness and the time devoted to it in the course of a patient visit. Complexity of care is more a function of a patient’s personality traits, such as maturity, adequacy, coping capacity, and social support structure, than of blood test results, X-ray and scan reports, or other objective findings. Hippocrates, primary practitioner of Periclean Greece, presciently summed up the root challenge of medical office scheduling when he said, It is more important to know what sort of person has a disease than to know what sort of disease a person has.

A middle-aged woman coping with a slow-growing malignant brain tumor is currently comfortable and arrives, accompanied by her supportive spouse. She requires a brief neurologic recheck, a refill of her antiseizure medication, and then she is on her way. A disconsolate young man, however, scheduled to see me for a minor and transient somatic complaint, a sore shoulder, casually mentions as an aside that he is recently divorced, laid off from his job, shopping for a gun, and giving serious thought to suicide. Suddenly his ten-minute visit swells to sixty, triggers unexpected phone calls to secure speedy psychiatric help, and dams the flow of patients seated in my waiting room. A modern primary care physician, needing to see as many as thirty to thirty—five patients per day to cover an onerous fixed overhead of a quarter of a million dollars per year, cannot achieve the elasticity of scheduling necessary to provide immediate, comprehensive, and compassionate care and service. Hippocrates never had to hustle.

There is no optimal method that maintains a steady stream, guarantees customer satisfaction, and keeps things fair. A classic approach to effective patient scheduling is the wave. Three or four patients arrive synchronously, each entering a maze of medical exam rooms, the laboratory, and the front-end business area. They each begin the process of updating personal information and reporting new physical complaints to a nurse. Weights are measured and temperatures are taken. Samples of blood or urine may be obtained, prescriptions are renewed, and a flurry of forms exchange hands. I then perform a juggling act. I may obtain a medical history from the man in Room 1, while the woman in Room 2 has an electrocardiogram (EKG) and the man in Room 3 has gone off to the lavatory to produce a urine sample. I move from room to room, as in a game of musical chairs, punctuated repeatedly by the hygienic ritual of thorough, compulsive hand washing. There are inevitable delays in the countdown. The elderly woman disrobing for her EKG conceals a surprising number of layers of clothing, even in July, which she sheds slowly due to the stiffness of her arthritis. If the man in the lavatory has an enlarged prostate, which is quite likely in an older gentleman, obtaining a small sample may take much longer than anticipated. Patient flow is impeded by slow urine flow. It is now only 9:30 a.m., and I am already running late. The next wave, due at 10 a.m., soon will be rolling in. In a busy primary care practice there is no catching up, and it is virtually impossible to make the trains run on time.

The artful part of patient scheduling is to keep the appointment book elastic enough to absorb an emergency case, an acutely anxious individual, or a shell-shocked new recipient of a dismal diagnosis. Yet there is little give in the system. The woeful shortage