Exhausted primary care physicians are providing deeply gratifying care, signing volumes of paperwork, mastering a bizarre billing system, and feeling increasingly bitter as our health care system grows in dysfunction while our input isn't sought out or is ignored.

So I offer the following wish list this holiday season.

1. I want to stop completing paperwork that costs me time and money — but helps others get paid. For example, when a patient presents to the emergency department (ED) with a serious fracture, that patient's care may not be covered by insurance unless we in primary care make a referral. We don't need to see the patient. The patient clearly needs orthopedics. But the insurer won't pay orthopedics unless primary care completes the referral paperwork.

The same thing happens with optometry and ophthalmology. Frightened patients rush to the eye doctor. Most of the time, they do need to see the eye doctor. But then they call their primary care physician, and we stop what we're doing to complete paperwork that will protect them from the bill.

2. I want to stop having to repeat myself. For example, anesthesia might ask me to send X, Y, and Z data for a patient who needs surgery. But I already sent the data to the surgeon whose opinion I requested. Is it unreasonable to expect health care professionals to communicate with each other about shared patients so we don't have to repeat ourselves?

3. I want easier coding and billing rules, but I don't want more new codes. One of my pet peeves involves advance care planning. I don't want to nickel-and-dime the system or my patients when I discuss advance directives with them, so I only bill for the service in conjunction with a Medicare wellness exam, which saves patients a deductible. As a thank you for my cost-consciousness, I get to complete the task of making sure the visit is 365 days from the last one, or at least I think that's the rule. I can't keep it all straight. And if the patient dares to want a problem addressed at the wellness exam, then I have to add a modifier and an evaluation and management (E/M) code, which means an extra charge, which means an upset patient.

Santa (or the Centers for Medicare & Medicaid Services) appears to be making progress when it comes to E/M coding. (See the article on page 6.) But changing the requirements for E/M codes isn't enough. We also need some relief from having to send notes for walkers, approve physical therapy plans, fill in numbers and dates from the oxygen supplier, and on and on.

4. I want systems that help me do the right thing. For example, when I need a computed tomography scan for a patient with suspected appendicitis, the patient and I cannot afford the time it takes to go through the prior authorization process. This creates a terrible incentive to send patients to the ED.

Many small practices like mine have also stopped seeing young children because we can't afford to manage vaccines. We need vaccines in unit doses, but that is not how we can order them. With a little paperwork, I bet pharma and the Food and Drug Administration could get this done. We do paperwork all day, so why can't they?

I realize that when we speak up and say what we need, we risk being accused of whining, but so be it. Those of us practicing family medicine are nice, not naughty. We still show up every day and mostly do a darn good job. All we want from Santa this year is a little help.