primary care medicine: schedule

I see patients from 8:30 or 8:00 am until 2:00 pm.

We have people say, “You are off after 2:00.”

Well, no. Most days I work for 2-3 hours beyond the patient contact time. Sometimes I come in early and sometimes it is from 2pm to 5pm and sometimes it is the weekend or into the evening.

So what am I doing?

  1. returning phone calls
  2. doing refills. To do a refill I check when the patient was last seen and whether they are due for laboratory.
  3. reading specialist notes and updating medicine lists, diagnoses and contacting patients to get tests or follow up that the specialist has recommended
  4. reviewing lab results and sending a letter or signing to be scanned and to be available at the follow up visit or calling the patient
  5. reading emergency room notes and hospital discharge summaries and setting those patients up for follow up, updating medicine lists and adding to diagnosis lists.
  6. dealing with multiple stupid letters from insurance companies questioning the medication that I have prescribed. Mostly I mail these to patients.
  7. running my small business: long term planning, short term planning, advertising, commercial insurance
  8. 50 hours of continuing medical education yearly
  9.  Updating my medical license, medical specialty board eligibility, business license, CAQH, DEA number, Clia lab waiver, medicare’s shifting rules, medicaid’s shifting rules, tricare’s rules, and 1300 insurance company’s shifting rules and medicine rejections and prior authorizations even for a medicine a person has been on for 20 years.
  10. Worrying about small business costs as reimbursement costs drop: health insurance. Retirement. L&I. Employees. Malpractice insurance, small business insurance, the lease, staff costs.
  11.  Discussing and updating medical supplies and equipment, office supplies and equipment
  12. Updating clinic policies and paperwork per the change in laws. Have you read the Obamacare Law? Over 3000 pages. HIPAA. The DEA. Recommendations from the CDC, federal laws, state laws, internet security, patient financial and social security security.
  13. Trying to track what we collect. That is, say I bill $200.00. Since I accept insurance, the insurer will tell me what is the “allowed” amount per me contracting as a “preferred” provider. The “allowed” amount is really the contracted amount. Then the insurance company either pays it or says that the patient has a deductible. This could be $150 per year or $5000.00 per year. With medicare I then have to bill a secondary if the person has it and then anything left is billed to the patient. Oh, don’t forget copays, if they don’t pay that we have to bill it. So to get paid the complete contracted amount, aka “allowed” we may have to submit bills to two or even three insurances and the patient. We might be done two months after the patient is seen.
  14. Trying to convince recalcitrant computers and printers and equipment that indeed, it doesn’t have a virus, oh, or maybe it does, and fixing them.

My goals are to give excellent care AND to work 40 hours a week. Half of my patients are over 65 and many are complicated, with multiple chronic illnesses.  When I saw patients 4 days a week for 8 hours, with an hour hospital clinic meeting every day, I also spent at least an additional 8 hours and more trying to keep up with most of those things above. The average family practice physician makes more money than I do. But they also report working 60-70 hours a week on average. I do not think this is good for patients or doctors or doctors’ families or their spouses or children. The primary care burn out report rose from 40% to 50% of the doctors surveyed.

We need change, we need it now, and we need to be realistic about how much work is healthy.

When I was still delivering babies, women would ask if I could guarantee doing the delivery. I would explain: “We do call for up to 72 hours. If you go into labor at the end of that, you would rather have a physician who is awake and rested and has good judgement. Besides, I’m a bit grumpy after 72 hours. ” And they agreed that they really don’t want an exhausted burned out physician.

I took the photograph of Mordechai, our skeleton, today. She is genuine plastic. I wish she would do some of the paperwork, but at least she lightens things by making us laugh. She gets various wigs and outfits and sometimes comes out to show a patient a hip joint.

I am NOT attracted to paperwork. I think I am repelled. For the Daily Prompt: magnetic.

 

3 thoughts on “primary care medicine: schedule

  1. Michael says:

    goodness what an insight into a pretty intense set of goings on!

  2. I don’t think people realize how burdensome our modern healthcare system has become for doctors. Everyone knows how expensive it is for patients, but nobody has stopped to think about the costs of running a practice that is compliant with all state/federal laws and dealing with insurance companies. My hats off to you. Quality over quantity is what I would want from my doctor any day!

    • drkottaway says:

      It’s partly just that people are complex: a study showed that the average primary care patient has four chronic illnesses. And there are guidelines for every one. I almost NEVER see “a simple cough or cold”. It’s walking pneumonia in a diabetic where I have to adjust the antibiotic dose for their reduced kidney function and it’s going to mess up their warfarin level….

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