family practice issues and general life events

Archive for August, 2011

Taking time for yourself

I have been meaning to get back on here and post for the past couple of days, but sometimes you just don’t know what to say.  There are plenty of medical conditions out there that I could write about,  but none of them seemed quite right, and those that are currently on my mind the most, cannot be written here due to privacy concerns.  So I waited a few days, and decided on something that we all need to do, take some time for ourselves.

 

In today’s world everything is fast pace.  When was the last time you went somewhere without your Blackberry, iPhone, Android, etc?  Do you even know?  I do, but mine is somewhat cheating.  While I was aboard the cruise ship last month.  We couldn’t get a signal anyway, so it was locked up in the safe.  Though we still took it with us while on shore, for emergencies, though both my husband and I did get online to connect.  But in the daily life, I don’t know.  In my husband’s case, he will not be leaving it behind at all until next Friday afternoon, when he can pass off call to another physician.  However, this weekend, he will be firmly attached to that phone.

 

Even being attached to the cell phone, we should take time for ourselves.  Time that we don’t have to worry about the kids, work, your significant other, and any of the other numerous obligations that we have.  I would say it should be a top priority, however, it is probably the most neglected aspect of health and well-being out there.  I cannot tell you how many times, I see an overstressed patient in tears in my office that when asked what they do for themselves, they look at me like I am crazy.  Almost all respond with there is no time for me, in some form or variation.  It is either their kids (the most common reason for females), their spouse, their job, and the list goes on and on.  This does not mean I don’t think that they have legitimate reasons for not tending to themselves, but the question remains, “How do you take care of everyone else without first taking care of yourself?”  The answer, you can’t very well.

 

I am not saying you have to go away for an extended weekend by yourself.  I have not ever done that.  I hear about trips with friends and believe that sounds wonderful, but while that could be taking care of yourself, it is not what I am actually saying.  I am more talking about smaller periods of time daily, or at least weekly, that is all about you.  You are free from worrying about making dinner, getting the kids ready for school, working, and just taking care of yourself.  Some people go to the gym, some for a walk, and some it could just be quiet time.  Whatever helps you to alleviate stress.  It needs to be a time that you can take a break from the world, and say “What about me?”

 

This time for yourself does not have to cost anything, and could be at your own home.  It is merely the time to recharge your batteries.  Many times I suggest some form of exercise, because it will release endorphins and help with many of the symptoms of depression the patient may be feeling.  It is also a health conscious activity, and does a lot to help alleviate the stress they may be feeling.  And it does not have to be running, or require a gym membership, for some a simple walk is enough, for others a full out run does the trick.  The important thing is that this is time for you.  Time that allows you to de-stress.  It allows you to become the person you like, and not the over-stressed individual who is crying because there is not enough hours in the day to accomplish everything you need to do.

 

It is an easy thing to forget, to take care of yourself.  However, if you don’t all of those other things that you have to take care of start to suffer.  To be the best you can be, you have to start with yourself.

When too much is never enough

I accepted a while back that I could not do everything.  I was not going to be the mother who volunteered for everything for their child’s school, the doctor who completely immersed themselves in their patients lives with no regard for their own, or the best friend that is always available.  Frankly most of my time is spent between physician and mother, I have few friends that I talk to on a regular basis, and even fewer that I see regularly.  This is ok, life is about choices, and sometimes we sacrifice one area for another.

 

However, we are currently undergoing some major changes at my clinic.  Were they necessary, could they have been prevented?  I don’t know.  I don’t know if they came about while I was spending extra time focused on my boys and taking care of their needs, and taking a much-needed vacation.  Well, actually I do know that the vacation had little to do with the changes needing to be made, but it could have resulted from time I was focusing on my children and elsewhere.

 

By the end of this month, all of my staff will be brand new, i.e. working for me for less than 3 months and not yet qualifying for benefits.  One of my front office is brand new, and we are attempting to convert to an outside billing system.  This was previously done in-house, and due to increasing requirements on time and needing to move staff around to cover holes, we have overlooked probably the most important aspect of any company revenue collections.  We are busier than ever and doing the work required to earn income, just seeming to miss the step of actually collecting that money.  I spent my Saturday morning looking at the Accounts Receivable for the past year, and it was terrible and depressing.  How did I miss it?  Well I can give you excuses of well I have been seeing more patients than ever, I have been trying to be a good mother, I have been trying to be a good citizen, and the list goes on.

 

We have known for a couple of months that we needed help.  In fact, we have been looking for someone qualified and fully trained for about 3 months.  The only takers have been, people neither trained nor having any experience, all wishing to tell me that they are fast learners.  Unfortunately, I have neither the time nor the desire to train someone for this all important job.  Add to that, I would argue that I am not the best one to train another for this job.  There are programs that certify people for this, and I am not certified, but I know probably as well as any physician, and maybe even better than most.  However, I do not know the tricks to fight for my money or all of the other little insights into being a successful biller or coder.  So we have decided to go out.  And let someone else try it for a while.  This is not to say that my employee hasn’t been trying, however, since we terminated another in the front, we had to move her around doing other jobs, leaving the vital job undone.

 

The other area we have a recent upheaval is our nursing staff.  We witnessed a recent surge in patients which was more than the two nurses we had could handle.  Again we had difficulty filling the position.  Whether it was the potential wanting to much money, not wanting to work as much, or other it took longer than we thought that it would.  Almost immediately after filling the first position, my long time nurse informs me that her husband is being transferred, so I would still have to find another nurse.  So we continue our search, only to be given notice by another nurse, stating that the hours, stress and money had been beat by another group.  So she was also leaving.

 

I have a problem with faulting myself for this situation, since we were attempting to alleviate some of the load and stress, however, anyone who has ever hired employees knows, the right fit is important.  A combination of work ethic and personality are very important.  However, maybe this is good.  It allows us to re-examine the work flow and find where the critical errors are.  There are issues we have been noticing for a while, but did not know how to fix.  Maybe a fresh slate is what is needed with new ideas to fix this.

 

The good news to this story is Monday morning, we will have a full slate of employees.  Actually one extra since my nurse who is moving is there until the end of the month, and can help train.  Maybe it will help with the morale of the clinic, all new employees.  There are advantages of starting fresh, however, there will be a slow down due to the need to train the new staff.  I will continue to wonder if there was something I could have done to prevent this drastic overhaul, but will never know for sure.  However, hindsight is always 20-20, but I did not have the ability to see it so clearly before.

Why I don’t like it when the Radiologist calls

As a physician sometimes you have to order xrays, ultrasounds, MRIs and CT scans. Most of the time they are no big deal. Occasionally there is a fracture, a slight blockage, a baby, etc. There might be something wrong, but it is minor and not anything that they need to contact you for. There report is enough. Or you can look at the xrays, and while some action needs to be done, it is not a big deal. It can wait

However, sometimes the radiologist does call. When they do, there is always something major wrong. There is always something that needs urgent if not emergent action. They never call to say hello, or ask if you are having a good day. I don’t get calls when the mammogram is abnormal and more views a needed.

No the radiologist only calls when there is something bad. There is a mass that might be a cancer in a kid, there is a blockage in the stomach that is causing the bowel to die, there is a large head bleed that requires neurosurgery and immediate transfer.

This is not to say I want them calling on every normal xray. Actually that would be quite annoying and inefficient. I just don’t like it when they do call.

Good times at the OOA

This weekend was spent in Oklahoma City obtaining some Continuing Medical Education from the Oklahoma Osteopathic Association. While it might not sound like the best time in the world, it does lead to some good times with some great people. It is funny that when you first get out you don’t realize that some of your biggest supporters are other doctors. I am not sure this is true in other professions, but in this one it is in many ways.

I don’t know, but it might be that as an industry, physicians generally don’t want a monopoly on patients. It is unrealistic and often feels like you are doing neither you nor the patient a good service. Son you know you need other physicians. It might also be something about how as an industry we are facing more and more regulations by agencies run by people with less education and training and understanding of what consistutes standard of care.

Though it is not easy to reach this conclusion. When you first start out, especially solo, you could think the world is against you. It is only through time that your realize that you aren’t. Physicians (generally) are willing to talk to others about a variety of topics, EMRs, financial planning, setting up an office, as well as medical aspects. I think that is wonderful. But unless you attend some of these meetings, you would never know.

The meetings are great for education and credits, and that is their primary function, but the social aspect and support cannot be denied. You hear about everyone’s families, the good and the bad and it is nice to have a sympathetic ear. Then you also get asked how you are doing, and often if there is anything you need.

The biggest concern, I heard this weekend, is what can we do for you? This was both at the national and state level. And while I am good right now, maybe that is the message we should be giving new physicians, how can we help you? I don’t know how much advice, I can give some one new coming out of residency, but I could sure tell someone everything that I did wrong. And that may be just as valid as how to do it right.

EMR and the family practice doctor

I am going to give my thoughts on the whole electronic health history debate.  It is probably worth about the same as most, less than some, and more than any of the politicians thinking that it is a good idea to implement.  All and all about 2 cents worth.  Why should you care what I think?  Because I am one of the people who are using it everyday, out in the office, and probably understand it more than those who are pushing for its requirements.

 

Back in 2005, when I opened my office with my husband, we decided to go ahead and “bite the bullet” and install the software.  The future was in front of us, and while in residency and in his moonlighting in ERs, neither had actually used an electronic medical record, we believed it to be the future and have been correct.  So we looked at all of the systems out on the market, well maybe not all.  We disregarded the “top of the line” due to their costs, and the fact we had just graduated residency and I was packed full of debt.  The less expensive ones just did not seem to do everything that we wanted, and soon narrowed it down to two.  And to be fully honest, the disrespect we received from eClinical works sold us on e-MDS as much if not more than their sales people.  Sometimes your competitor is your best friend, and your sales rep is your worst nightmare.  But this is not about the individual record keeping system, only a little background where I am coming from.  I have licensing for one, and use it on a daily basis.

 

First of all what EHRs are not.  They do not make you a better physician.  They do not make things easier to get your charting done, sorry it doesn’t.  There are functionality issues where you can enter templates, and preload, which do add to ease, but with all of the check marks that are now added to meet meaningful use guidelines, the ease of it, has been tempered by having to make sure that every box is checked. Which I guess is easier than hand scribing it out.  However, there is still significant time spent documenting after the patient leaves, that I would not call electronic medical records necessarily a time saver.

 

I would like to say that I look forward to the day when all of the consultants I use fully adapt an EMR.  At least those that handwrite rather than transcribe their notes.  Talk about terrible to read.  I usually see the faxed version of the note, integrated into the documentation.  I just hope that in some instances that the specialist does surgery, so I can know what they were thinking.  Then they have to use the hospitals dictation system.  And I can read typed information.  So for legibility reasons alone, there are definite benefits to the electronic health keeping system.

 

Drug interactions are a very beneficial part of the system. There have been times that rare interactions or interactions in disease states have popped up when I have entered a medication.  Sometimes this has helped me maintain a preferred medication due to potential side effects in and interactions and sometimes it has prevented potential complications.   Drug interactions don’t remain constant and new black box warnings seem to be increasing in frequency, so the back up is a nice feature.

 

The EMR can remind what tests are due, and if done right all of the test results are available at your finger tips and you can look at the trending.  These are all fabulous features of having it electronic.  Patients can see it, and if need to you can even print off the page at the visit.

 

Electronic medical records will probably be beneficial when they are fully integrated in the future.  However, they do not make better physicians. Patients are now heard to complain that the doctor spent the whole time typing into a computer.  How this is different from writing in the chart I don’t know.  Maybe those practices have not implemented the use of tablets, and the physician’s back is turned to the patient.  Costs of these systems remain high for software alone.  This does not include the constant need to upgrade current system.  Learning new aspects of the software and trying to implement needed aspects of the requirements.  The interface is ever fully functioning would be great, being able to pull down from a cloud visit notes from other providers, and what their documentation shows could help decrease costs.  However, risk from hackers and viruses remain a concern from both the patient and the provider.

 

The biggest difficulty with the implementation is that those that are creating the guidelines do not appear to be working with either the developers of the product or the providers and hospitals that must utilize the product.  It is easy for them to say that all prescriptions should go electronically, but not all pharmacies are ready to do so, or do even all state laws allow for all prescriptions to be transmitted that way.  Deciding that this is what constitutes meaningful use should take into consideration what is currently possible, and the time frame for it to become fully possible in the future.  Some of the requirements that are to take place in the near future seem to be almost impossible hurtles, especially when you consider that there is about to be a conversion in how everything is coded in 2013.  And any honest vendor, physician and insurance company can tell you that the conversion in itself may cause its own difficulties and meltdowns.

Stop and reboot

When life gives you error messages sometimes you just have to reboot.  It is not necessarily as easy as it is with a desktop, there is not control-alt-delete on life.  Nor is there a convenient power button to start all over.  But there are often signs.  Signs that there are changes needed, but you might try ignoring them.  However, the longer you ignore them, the more necessary that this reboot is necessary

 

Life like business and even computers occasionally needs a reboot.  The screen becomes frozen, or you are getting to many errors to be productive.  It is never something that you look forward towards, but sometimes just the change and reboot breathes new life into a stale existence.  Things that you stopped enjoying and even began to dread, become something new and exciting.

 

Sometimes rebooting is simple like a new hairstyle.  Sometimes it is more difficult like having to move to advance your career.  Sometimes it is something in between.

 

In business, when sometimes a staff turn over is necessary.  It is not always wanted.  It is next to impossible to find good help today.  When you hear about all of the layoffs, you think it would be a great time to pick up employees, but when you try to hire new staff, that is not always so easy.  Sometimes though, when you stop, you cna see the opportunity that you would have not otherwise realized was there all along.  Sometimes when there is a major change in a business, a sudden increase in client base, or other major change, there needs to be some changes that you did not previously think was needed.

 

Sometimes it is the result of individual staff needing a reboot.  They are no longer feeling needed or feeling overlooked or overworked.  Sometimes they have their own opportunities and need to reach and grow to achieve their own goals.  Major changes are difficult to obtain and even more difficult to embrace.  However, hard it is, there are opportunities that are neither sought, nor obtained without difficulty.

 

When you think about think about it, most of the successful organizations in the world have had to reorganize at one point or another.  Sometimes things start to slack, or they are not as motivated as you are.  Any of these things can be detrimental in life and in business, and a reboot can breathe new life.  For a company that does not change or grow, faces the possibility of withering away and dying.

Regular check ups

Sorry about the length of time between posts, but returning to real life seems to have gotten in the way.  It is funny how returning to vacation always does that to you.

 

Today I wish to address the importance of regular check ups.  Check ups are an easy thing to overlook, and once all of the vaccinations are complete, parents tend to focus more on sick visits and such.  However, regular check ups, about once a year for children over two, are in fact an important need in a child’s life.  It is through check ups that developmental delays are addressed.  For example if you only bring your child in for strep throat, which is usually a shorter work in visits, a delay in speech or other aspects might be missed.  And in the case of speech, the earlier the intervention, the better the end result might be.

 

Additionally, important tests such as lead levels, and blood counts can be drawn at routine visits to make sure that the child is not anemic, or have to be treated for too much lead which can lead to development problems in brain development.  Lead level tests are especially important for those living in old houses that might have lead based paint, which could be covered up by newer paint or still there.  And in recent years, toys from China keep being recalled due to lead based paint in them.  These make no one immune from the need for lead testing.  Current recommendations are for lead tests to be done at 12 and 24 months and when exposure is suspected.

 

For those with healthy children, not needing vaccinations, health check ups are also important.  It is at these, that time is allowed in the schedule for questions that parents might have, and to discuss important landmarks.  Sometimes the questions are simple, like child number one was already walking at this age, why isn’t he?  Sometimes they are more complicated, and might need further work up and discussion.  Additionally, it is even more important today with the rapid increase in childhood obesity.  Early intervention can help to prevent the diagnosis of Type 2 Diabetes in children, and discussion of appropriate food intake is always important.  While juice is often marketed on the television as a healthy alternative to soda, many juices out there have just as much if not more sugar than soda, and in any case should be limited to two servings a day.

 

The older child has issues such as puberty, diet fads, drug and alcohol usage.  All that should be address, as well as STD prevention.  These are important to have before the child is sexually active.  I can’t tell you how many times, I have had these conversations with teenagers which have no idea, what STDs are nor what they can cause in the long term.  And many times, parents are shocked to find out that their child is sexually active.  So it is important to address all of these issues before they are a problem

 

Anyway, children in all stages of development need to have routine checkups  If only to prevent potential future problems.  In most cases it is easier to prevent the disease from happening, than to treat it later

 

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