Long notes and unhappy patients.

A patient of mine saw a cardiologist recently.

His previous cardiologist has retired. The patient had a cardiac bypass in the past, he has a stent, he has known coronary heart disease and he’s in the young half of my practice. That is, under 60.

He had not seen a cardiologist for 2-3 years because he had a work injury, worked with Labor and Industries, the case was closed, he couldn’t go back to work, he found a lawyer. He lost his regular health insurance along with the job, so couldn’t see the cardiologist.

The L & I case is reopened. A physiatrist recommended specific treatment that was not done, and that allowed the case to reopen.

The specific treatment center then notes that he has heart disease and that he needs clearance from a cardiologist. I set him up with a new cardiologist.

“How was the visit?” I ask.

He shrugs. “The staff was nice.”

“I have the note.”

“The cardiologist spent under ten minutes with me. It was clear that she was rushed. She did not seem very interested. It was difficult to get my questions answered.”

“Her note is six pages.”

He snorts. “Great that she could get a six page note out of that visit.”

“Do you want a copy?”


He is cleared for the specific treatment.

I have no doubt that the cardiologist spent more than 6-8 minutes on his visit and his note. But not in the room. Other people are entering the information filled out in the waiting room, medicines, allergies, past medical history, family history. Hopefully the cardiologist is reading my note and letter. But the problem is, doctors aren’t doing it in the room. So the impression left with the patient is that we spend 6-8 minutes on their visit, we are late, we are rushed. Doctors are looking at data. They are not listening to patients.

Medical Economics, a journal that arrives without me asking for it, says over and over that we need more physician “extenders”, that we need to have people doing the data entry, people doing the patient teaching, more people and machines….No. They are wrong. We need LESS barriers between us and the patients, not MORE. We need more time with patients. Every single extender we add burns physicians out more, because the salary has to be paid AND more patients seen faster to do that AND we are still ultimately responsible for knowing and reading and absorbing every single piece of information that is placed in that patient’s chart. An extender is NOT an extension of my brain and an extender is another person I have to communicate with and train.

Just. Say. No. to the managers who pile MORE barriers between the physician and the patient. NO.

It just makes me so mad that he lost his health insurance BECAUSE he got injured at work and so then his heart disease goes untreated as well… can’t afford medicines…if he then has a heart attack while uninsured we lifeflight him to Seattle, it costs a fortune, he loses his house and property and then is on medicaid and may end up on permanent disability, and what are the chances he returns to work? The US medical corporate money grubbing is insane. Single payer, medicare for all, make the US great again.

8 thoughts on “Long notes and unhappy patients.

  1. Oh by the way, it was leftover, still-unprocessed barium tablets from a procedure he sent me for…

    • drkottaway says:

      …oh migawd…. Way to mislabel. I give each patient their first note and say their homework is to check it….

  2. Oh the stories I could tell about my last three years of medical treatment. Appalling!

    16 specialists only to discover the very first doc (my pcp at the time) missed something in my first visit.

    The highlight for me was to have same pcp call me in the middle of the night to inform me that a routine hip ex-ray turned up some bullets or shrapnel in my lower abdomen, and that I needed to see a surgeon right away. He then warned me of the dangers of having an MRI by describing explicitly what would happen.

    When I told him the information had to be incorrect…I’d never been shot, he actually said “well, maybe you have forgotten? You are getting up there in years.”

    I was 65!

    So very glad you are on the planet!!

    • drkottaway says:

      Chart mistakes stick like glue. I have had patients cry in my office when they have gotten chart notes from other providers and have been labelled an alcoholic or something is dead wrong. And my sister read every one of her notes. She said her cancer got so complex that No One got the history right.

  3. Other jobs have “extenders” too. I worked as an extender for a scientist with a big lab for a while. I often described that position as “the administrative work she didn’t have time for or didn’t want to do.” The stakes weren’t as high as they are for working with patients (so I think your situation is even more problematic, as you describe). However, the same dynamics are taking place: push for excessive “productivity”, burnout, and one hand not knowing what the other is doing. I believe in that situation the solution is to have smaller lab groups and to cap the number of trainees who could be working in a lab. It seems to me that there are also only so many patients a doctor can handle without the quality of care suffering (and the doctor’s mental health too)!

  4. So sad to come across stories like this again and again, and in so many different parts of the world.

  5. shoreacres says:

    I’ve been traveling and having a hard time keeping up with things blogwise, but had to add this. My 92 year old aunt’s doc has left “The system” and has established a concierge practice. For a hundred dollars a month (this is in the KCMO area) my aunt gets a whole variety of things — including access to her doc by phone, office visit, etc. For $125 per month, other services are added for people in the assisted living place where she lives — like medication monitoring and someone to be sure the week’s pills are distributed correctly.

    Her doctor simply tired of the demands for “productivity” in her group practice, and the insistence that she delegate so much to others. Which is to say: you certainly are on target here, and some people are discovering the truth of what you say.

    • drkottaway says:

      I have not gone to concierge because so many of my elderly folks are on a fixed income and medicare. But I have a tweaked practice where I see patients from 8:30 to 2 and then do the paperwork, phone calls, refills, referral, read the labs and notes and specialists notes and old records. The goal is to work forty hours, not 60-70. Good for your mother’s doctor!

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