Time is a touchy subject with most physicians, who complain that they're spending more of it filling out forms and dancing around bean counters than diagnosing disease and talking to patients. It's just as sensitive for patients, who complain of overscheduling and long waits for shorter examinations.

Actually, according to the National Center for Health Statistics and the American Medical Association, which examined the duration of office visits from 1989 to 1998, the length of the average doctor visit has increased (albeit by only a minute or so), even as caseloads grew by nearly a million visits. The perception persists because a so many outside issues influence the way doctors must manage their practices.

Take pharmaceutical advertising. Really, many doctors say, take it away. Researchers at the Harvard School of Public Health, Massachusetts Institute of Technology and Harvard Medical School found that direct-to-consumer advertising more than tripled from 1996 to 2001, rising from $800 million to $2.7 billion.

"They're in the business of marketing the drugs, and they're very good at that," says Dr. David Stutz, a 25-year general practitioner. "The information is not necessarily bad, but a lot of inappropriate demand is being generated."

Many things can affect medical care, from transient populations (which affect continuity of care) to ever-shifting HMO doctor pools and workplace insurance for younger people who change jobs more frequently, he says. "But One of the biggest changes is that 15 to 20 years ago, physicians essentially controlled the information." Today, patients get information from advertising agencies, government legislation, even the World Wide Web.

Advertising is also an issue with plastic surgeons like Dr. James Marsh. Because anyone with a medical degree can perform plastic surgery, he says, "It blurs the line between who's a real plastic surgeon and who's not."

But he is kinder toward the Internet. "It used to bother me. Now it actually makes my job easier, because I can point to misconceptions. And it's nice that you don't have to educate them from the ground up."

"There's no way a doctor can have all the information," adds Stutz. "Patients have access to much more information, which is fine."

But not everything from the Web or other sources is correct, notes Shoemaker. "Along with all the other time constraints, now GPs have to manage the misinformation that's out there," says Shoemaker.

Some doctors are learning to use the Internet to their advantage. Instead of passing out potentially outdated brochures, Dr. William Tingle of Florida Urology Specialists directs patients to any number of medical Web sites that are continuously updated. "Most people are intelligent enough to filter out the garbage," he says.

A bigger threat, doctors agree, is government legislation that is drastically changing the way doctors can treat their patients. The Health Insurance Portability and Accountability Act of 1996 (HIPAA), originally intended to ensure the privacy of patients and the security of their medical information, is a prime example.

In some ways, HIPAA is working. For example, it has discouraged pharmaceutical companies from sending follow-up mailings to patients without proper authorization from patient and doctor. But the act also requires physicians to maintain administrative, technical and physical safeguards that limit the release of a patient's medical information-even to attending doctors. The American Medical Association reports that some physicians have been unable to check on patients who have been transferred to another hospital.

"HIPAA is one of those well-meaning things that has added a lot of garbage," says Stutz. The new rules require health providers to use "appropriate administrative, technical and security safeguards to protect the privacy of protected health information-including oral communications," leading some physicians to wonder if they need to soundproof their offices. Violations, says Stutz, can lead to draconian financial penalties.

"It increases the burden of doing business with no benefit at all," adds Shoemaker. "We have to get a signed authorization to leave a voice mail confirming your appointment."

Or say your husband is being treated for diabetes, but hasn't been to his doctor since last April. Forget calling to check his last cholesterol levels. They won't give them to you until he comes in and signs an authorization form.

As a result, doctors are flooding their patients with such forms. "If there's anybody who might call about your health, whether it's a relative, spouse, or your attorney, put them on the list," Tingle advises. "If they're not, I can't even confirm that you're a patient of mine."