Last week my primary care doctor told me that she would be retiring by the end of the year. Retiring!!! In a time when we need more PCPs than ever, it is sad to see another great one go. A Johns Hopkins trained internist, a superb clinician, companionate and caring, and still doesn't use a computer while seeing patients, has finally decided to throw in the towel. But why?
I will never know the exact reason, but having spent the last few years combing through regulatory and compliance requirements for physicians, I wonder whether that pressure played a significant role in her decision to retire. After all, year after year, in a nationwide physician survey, having too many rules always comes up as the number one challenge providers face (23%).
PCPs are at the frontline of any patient's health. They are the driver in the patient's healthcare journey. They employ various clinical decision-making processes in diagnosing and preventing severe health conditions. One such tool is prescribing controlled substances (such as anti-anxiety or pain medication) for short durations to treat acute illnesses.
To understand the regulatory bureaucracy a doctor must go through to prescribe such substances, let us analyze the steps a doctor needs to take when they prescribe an anti-anxiety medication like Ativan.
Prescribing is also part of a critical diagnosis process, called differential diagnosis, where the doctor prescribes a drug temporarily to rule out other conditions.
- The physician must check the state PDMP data for the patient to ensure the patient has not been prescribed Ativan recently. If the doctor is near border states, the doctor must check all those bordering states. Did I mention, the doctor must have a credential to check those states. The interoperability has been improving, but it is still the doctor's responsibility (unfortunately).
- The doctor must save the PDMP report copy. Many doctors assume that just checking is good enough, but in an audit, state PDMPs are not obligated to provide search history and the results to the doctor. Also, the state PDMPs are not real-time, so a doctor will be wise to save all PDMP reports to show the data that was available to them.
- CDC and State regulators recommend that the patient sign a controlled-substance agreement before initiating any controlled substance (aka Ativan). So the doctor must have the agreement ready, spend time to explain the agreement, and have the patient sign it.
- Many regulatory bodies state that patients should also be tested for illicit drugs before prescribing a controlled substance.
- Now the most demanding step. Each state's legislators enact their own control substance prescribing laws, and the rules can vary significantly between states. The doctor must follow these laws to protect their license. I have checked pretty much all state laws; most of them are written in legal jargon–very hard for a non-lawyer to understand.
A doctor must perform all these steps to prescribe one week of Ativan. Now, in reality, many doctors delegate these tasks to a medical assistant, but the doctor is still responsible for the correctness of the work. If there is any issue, the doctor's license and professional reputation are at risk.
Don't get me wrong. I am all for meaningful, easy to implement regulations. How that can be done will be a topic of a future post.
For now, the doctor has four choices:
Any good doctors, like my PCP, will follow Option 1. Because they believe that prescribing Ativan is the best clinical decision for the patient, even if that causes significant additional work. They will be torn between what is best for the patient and managing stress about all the compliance challenges; until one day, they will throw in the towel and leave practicing medicine altogether.
The increased regulatory burden and stress that we put these physicians under is costing us exceptionally well-trained and skilled doctors. And, in the already rapidly growing physician shortage, we cannot afford to lose another doctor due to preventable causes - such as an easier legislative burden on the practice of medicine.