family practice issues and general life events

Posts tagged ‘paperwork’

Why your doctor is running late.

I know it is a stereotype that seems to take effect over and over in real life.  You go to the doctor, and he/she is running late.  It is a standard joke, and I have even heard of others attempting to bill the doctor for the time they waited because the patient’s time is also valuable.  Which it is, but are we talking billable hours, quality hours, life saving time.  What kind of time are we talking about?

First of all, let me say, that if you doctor gives the impression that your time is not also important, there is something wrong.  However, there are legitimate reasons why your doctor is running behind.  And rarely even though based on popular opinion is it due to talking overly much to the drug rep who comes into the office bearing gifts, golf outings and fabulous trips.  I wish that is the easy reason why I often run late.  A paid vacation would be wonderful, but those days are long gone, and were before I was ever licensed.  And if I spend time talking to a rep in my office it is so that I can get samples of a medication that might help my patient.  End of story.  I don’t collect money from them, occasionally they buy me a pizza at lunch so that they might detail me on their product and why it is better than their competitor, but if I am going to write for a medication, I will do it based on efficacy.  First in clinical trials, and then based on my patients.  So no, I am not running behind because of the pharmaceutical rep.  And if they come in, and I am running behind, often the time spent is merely to give a signature between patients.

I do meet with reps, and I am not ashamed.  I think that they help with treating my patients.  It is not that I believe their entire spiel, I am not that dumb, but they help a lot by providing samples, which allows my patients to try products before they have to pay copays or even pay for the full prescription.  And it is necessary, because despite what the people at Wal-mart tell you, not all medications have a $4 equivalent, and in the case of COPD, there is not a medication that follows the gold standards for treatment that is generic.  There might be a couple of different brands, but there are no generics.  However, they actually take up little of my day individually.

Most of the time, I am not running behind because I slept in late, or just was moving slow.  While it has happened, it is a rare day for that to happen.  Most of the doctors in my town, start their day by rounding on patients in the hospital.  My husband sees anywhere from one patient a day to 16 yesterday.  Since he usually sits around two or three on the inpatient, the 16 took considerably longer to see than normal, so he got to work about 45 minutes late.  In our clinic, most of our schedules are made 6 months to a year before, so there would have been no way to account for that amount of patients on Monday when it looked like a possibility

Much of the time, running behind schedule has to do with the patient complaint.  They take longer than the front schedules for.  This is not to say that patients are doing something wrong, but more than once I have seen someone worked in for a sore throat, only to have them say as I am walking out the door- “Oh and by the way, I have been having these chest pains.”  Well, I cannot tell you what my malpractice carrier would say, if I answered that “oh by the way” with “well stop at the front desk to schedule an appointment to find out what might be causing that.”  I guess with that complaint, I could send them to the ER, but well I have already done the exam, and gotten vitals, and most of my patients would be very angry if I sent them to the ER.  (This is not to say that if someone calls to tell me that they are having chest pain and shortness of breath, my front office has not been instructed to advice them of heading to the ER to make sure they are not having a heart attack, it is a little different after the exam)  And I would estimate that at least 10% of my exams a day have an “Oh by the way.”  Not always are they so bad as chest pain, but usually they do tend to increase the amount of time of the visit.

I might also be running behind because a patient has come in for one reason and they tell me that they have not been able to sleep since their husband died last week.  I cannot see how as a physician or a human, I can just stop them and say, “Well that is nice, but why are you here?”  Or “well that is too bad, but the patient in the next room has a sore throat, and well your 15 minutes are up.”  That is not what I do.  I am a family practice doctor, and in my mind, giving them a sympathetic ear, and any other comfort I can provide comes with my job description.  I would hope that all citizens of the human race would do the same.

I might be running late, because frankly I over-booked.  As terrible as that might be to say, but I do it frequently.  Why?  Well first of all, I have patients that have chronic conditions that need to be see frequently.  Those appointments are set up at intervals between a month to three months in advance.  So they have been there.  Next there is a group of appointments that are following up from an illness, ER visit or hospital stay.  These are set at intervals between one to two weeks.  Now while we try to cap those visits at a certain number, there are also appointments made available that day for work ins/sick visits.  And truthfully, I would rather fit as many in that day for a sick visit that I can, than have my patients wait, or visit the ER or the urgent care.  I am possessive about my patients.  They are mine.  I know their allergies, I know their history, and I know them better than any other doctor.  So I want them to see me whenever possible.  And truthfully it is easier, if I take care of their sick visit, because then I don’t have to figure out what someone else did.

And that leads me to another delay.  The other patient went and say a specialist, went to the ER, discharged from the hospital, etc.  In the future when interfaces are seamless and electronic records are readily available, I will not have to figure out what happened where.  It is very common for an ER follow up, that the patient tells me that the ER gave them some white medication that didn’t seem to help.  If it is the Emergency Room here in town, I can get access to the records, otherwise I have to stumble through and figure out what treatment they received and whether they need to see another specialist, and whether there are any medications that need to be changed.

Then there is the various exams that are required for work, medical equipment, school, and/or various other agencies which all take time and have requirements that have to be met.  And often these are brought up during the routine medication refill.  Seriously there is no winning in these instances, because few patients are happy if you make them come back for the paperwork and rarely is the paperwork merely one or two pages.

Additionally, there is a seemingly endless requests for medication refills, lab results, and radiology results which all must be reviewed and determined what needs to be done.  This includes consults from specialists (some of which are not legible) and management of more referrals.

All of these reasons contribute to why, I often run between 30 minutes and an hour behind.  I am not crazy about running behind, and I do apologize.  Because I am sorry, and I don’t want to keep you waiting, but I have between 30-35 patients on an average day, that I want to give personal time and attention.  I want to give them the care that they deserve.  I would like your visit to be as personal and comfortable as possible as it is to go to the doctor, but at the same time, I want to give the consideration to everyone.  One of the biggest complaints you see about doctors is that they don’t listen.  Well maybe I don’t want to be that doctor, and maybe I listen for too long.  So maybe your doctor is running late because in an attempt to make sure that your problem can be addressed, they take the extra time to listen and address concerns.  Maybe they are trying to teach better nutrition, making sure that you are receiving quality care.

So the next time you are annoyed that your doctor is running late, ask yourself do they take the necessary time with you?  Do they spend time listening to your problems and concerns?  And if the answer is yes, realize that maybe they are trying to do it for all of their patients

When did my career become a secret?

A couple of days ago I noticed something. When people ask me where I work, I don’t usually introduce myself as a doctor.  It was one thing, when buying a car, that I would off-handedly say, “I work at the hospital.”  You are always told adding Dr to your name adds zeros to every purchase, buying a car, building a clinic, buying a house.  Anyway, in purchasing, you just don’t do it.

However, this time it was different.  I was eating dinner with my children at the Olive Garden, when the waiter asked what I did for a living.

I was wearing scrubs, so the question was initially, “So did you work all day.”

“Yes.”

“So what do you do?”

It was not the waiters fault, he was perfectly hospitable, taking care that our table had drinks and attention that anyone would appreciate.  We talked about the iPad 2, since I happened to have both children’s and mine with me.  And if I thought it would be a good deal to buy one, and if we liked ours.  All perfectly pleasant.  It was only when he came over during a discussion with my oldest, as to why I could not donate blood at his school’s blood drive the next day.  (Previous years, I have, but this year it was on a Wednesday, and most Wednesdays I barely have time for lunch much less time to drive 30 minutes to his school, donate blood, and return to work)  So I pulled up my schedule on the iPad, and showed him how full it was.  Still not overly impressed, he said, what about after work?  At that point, I promised him, if by some miracle of miracles, I were to finish by 4 pm, I would donate blood.  However, since I have yet to get out of the office by 530pm on a Wednesday in about 8 months, well it probably was not going to happen.  And this is when the above conversation happened.

I don’t know why I stuttered.  I am not really ashamed of what I do.  Obviously I would not be blogging about it online if I were.  But stutter I did, as I admitted that I was a physician.  Admitted, is this what the once noble profession I dreamed of being as a child came too?  Or maybe it was that I was caught off guard, since it was an early dinner due to having to leave work early in the afternoon to take my youngest to speech, and then kill time between therapy and a skate party.  And maybe that I was worried I would have to explain.

I spend a lot of my day explaining things.  Why I don’t take call, why I don’t go to the hospital regularly, why I have no desire to work in the ER, why I leave early on Tuesday and don’t see patients on Thursday.  And maybe that was the reason.  However, he did not ask for explanations, he actually was reassuring that my career was not equivalent to that of a drug dealer, even though some days, I think that is what I have become, at least in the eyes of some patients.

Maybe I spend too much time online, reading the terrible things people say about doctors, how they make too much money, they rush in and out of rooms too fast, they take too much time to get to their room, that they just don’t care.

I heard a joke once in training that the person who yells out first “Is there a doctor here?” is probably a physician themselves.  And sometimes, I wonder if that is true.  The days, weeks, months, years of fighting public perception as a money hungry individual willing to throw their patient under the bus for a dollar on one side, and the fighting for the dollars rightfully earned trying to provide the patient care that they deserve may have worn us down.  The time spent fighting against liability claims and fear of lawsuits despite no wrong doing, maybe those have worn us down as a profession.  The stories of physicians who have stopped to help someone on the side of the road and despite no wrong doing receiving a lawsuit for a bad outcome.  Maybe that is why we no longer stand up and say I am a doctor.  Or maybe, I just I don’t want to be chased through the grocery store to look at a mole.

And in my case, where my husband and I made the choice where he would take my call, so that one of us could be at home at night with our children, maybe I just didn’t want to explain one more time, why I don’t go to the hospital.  It is not that I can’t, it was that I put my kids before my career.  It is the years spent justifying why I don’t do shifts in the ER like my husband.  It is the time spent alone, at night, wondering if I made the right choice.  Did I do what was best for my patient?  Did I make a difference for the better?  Or what am I missing on that patient?

For the most part, I love my job.  I like that I am in most of my patients’ lives.  In many instances, after they get a recommendation from a specialist, they come back and ask me what I think they should do.  Or if they could have a second opinion, not necessarily that they disagree with the first, but that it is a major decision and they would like to have another perspective.  I don’t make as much in my clinic, as my husband makes doing his shifts in the ER.  I see the reports as to doctors not choosing primary care residencies, and I understand.  The money is not as good, and most of us graduate with a large amount of debt.  And you have to spend a large amount of time fighting, fighting insurance companies, fighting for payments, and watching the general population equate your training with that of a midlevel.  Even though you have twice as much training, 4 times as much debt, and way more liability.  And then at the end of the day, you notice the pile of paperwork- not visit notes, but other paperwork.  Prior authorizations, home health messages, home health certifications/re-certifications, various forms for patients regarding why they cannot work, disability questionnaires, and random notes that the patient wanted you to write for them yesterday.  Add to that orders that the specialist decides that they want done, but don’t want to obtain the prior authorization themselves, despite having the pertinent data needed to get the test approved, and yet they don’t send it to you.  So I understand why students are not choosing a career in primary care.

And maybe it is just a combination of all of those reasons that I don’t introduce myself as doctor out in public.  At maybe, just maybe that is why I stutter when asked what I do for a living.

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