When the topic of paperwork comes up, Canadian doctors start to sound uncannily like Eeyore, the depressive donkey from Winnie the Pooh's Hundred Acre Wood.

In one scene, Christopher Robin asks how long it will take to get an unusually plump Pooh unstuck from Rabbit's doorway.

"Days... weeks... months..." Eeyore gloomily mutters in his usual despondent, resigned tone. "Who knows?"

That's the same melancholic tone Canadian physicians have adopted when they wonder how long it will take to complete the piles of paperwork they face day in and day out.

"You can't fight it," moans Dr Geoffrey Holdway. "You can't escape from it. And God help you if you go on holiday."

It's a pernicious trend: the paperwork just seems to keep piling higher and higher.

The new NRM Survey of Medical Practice 2007 confirms it: paperwork was Canadian doctors' top practice complaint last year, with twice as many doctors complaining of it in 2007 compared to the previous year (see "Too much paperwork," above). Forget remuneration, forget wait times — paperwork is fast emerging as doctors' biggest problem.

PAPERWORK PURGATORY
"We have become the gatekeepers," says Dr Holdway, a family physician in Hamilton. "If someone needs a diet plan, or welfare, or a bus pass, there's a form Dr Holdway has to sign. That's what society is asking of us. You can bitch about it, but there isn't a way around it."

"Death certificates, sick leave notes, paramedical requests for therapy, applications for pharmacare — all that paperwork is tedious and incurs no fee charge," complains Vancouver FP Judy Kin-Man Lee.

And then there's the medicolegal report, the piece of paperwork most feared by physicians. "You have to sit down on a Sunday and go over all the notes and give an opinion, then you have to type it, and it's going to come back to you and you have to go through it again," says Dr Holdway. "That's a lot of work."

Secretarial staffing shortages and staff turnover both contribute to the growing frustration with paperwork. That's especially true in places like Calgary, where clerical salaries have risen sharply in recent years, and in rural and remote parts of the country. Dr Chau Nguyen, an infectious diseases specialist in St John's, Newfoundland, says trying to find good help is almost futile. "I can ask people to come but it takes a long time," he says. "Here in Newfoundland, the payment is the lowest across Canada, so we have to give people some kind of incentive — financial, mostly — to subsidize the move."

There was, however, one bright spot recently for doctors inundated with paperwork: last summer, the federal government finally relented on its long-standing requirement to have a professional — which for most people meant a doctor — sign off on passport applications, a service for which it was illegal to charge. "Thank God!" says Dr Holdway.

HOW TO COPE
Passport changes notwithstanding, the volume of doctors' paperwork and their complaints both continue to rise. In response, a burgeoning cottage industry has grown to help doctors solve the problem.

"It's always frightening when you go into a clinical practice and you see piles and piles of medical records — sometimes in the trunks of doctors cars," says Rick Jamison, the national director of consulting for the CMA's Practice Solutions company. "We go into a medical practice and review it in terms of efficiency." He says a lot of the inefficiency he sees is a result of bad time management, especially when it comes to paperwork.

Setting up an electronic medical records system can be a major help, he says. Referrals, prescription renewals, patient visit notes — these can all be computerized. The software isn't perfect yet and there are bound to be problems during implementation and later on, but that's often worth it considering the benefits. "I beef about it, but I prefer the computer system to what we had," says Dr Holdway.

What about all those forms you have to fill out for insurance companies, government agencies, summer camps and other such demanding organizations? Start charging patients for your time, suggests Mr Jamison. "Often physicians have $5,000 to $10,000 in uninsured services they could bill per year, and that's certainly worthwhile." He's observed that older doctors often neglect to consider billing for uninsured services. Younger physicians tend to have a better sense of the value of their time, he says. "They know they should be paid for what they do." You can start billing for uninsured services yourself or you can use one of the several third-party systems available.

But keep in mind that hiring consultants to take care of your uninsured services billing or to ameliorate your practice management and computer system can get pricey. For a typical five-doctor practice, for instance, hiring Practice Solutions costs about $12,000. "A lot of clients tell us that fee is recouped in the first year," says Mr Jamison. "In Saskatchewan we reviewed a speciality practice and one doctor had a billing issue — we caught $13,000 in missed fees that they wouldn't have recovered."

The popularity of practice management consultancy is growing fast. "About 10 years ago we had one part-time consultant," Mr Jamison says. "Now we have 12 across the country full- and part-time. Sometimes we're booking four to six months in advance." The reason, he says, is simple. "Younger physicians out of med school want to have a lifestyle where they can go home and let someone else deal with business."

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