For Thursday Doors.
This is for photrablogger’s Mundane Monday #129.
We were two of the three first responders to a house fire across the street and two doors down two weekends ago. The house was an inferno when we got there. Both the resident and two cats got out. The fire was in the morning. We returned in the evening and walked around. It is terrifying to see what melts, what explodes, how fast the destruction can happen.
And sending love to the injured and lost in Las Vegas and still thinking of all of the hurricane victims.
I wish today were mundane.
This is an early morning photograph, downtown, not this year.
It was frightening to fly back from Wisconsin last week and have the plane descend into smoke in Seattle. The smoke from fires in British Columbia and Washington blanketed the city. I am used to descending into cloud, but smoke looks brown and was neither opaque nor transparent. Haze.
I missed the worst air, but the smoke still bothers me. One afternoon my receptionist and I both were having trouble with eye irritation from the bad air. My clinic is in a 1950s building and closing all the windows and doors is hot! No air conditioning.
I am hoping that we make changes to slow and mitigate climate change and global warming: I don’t want the world on fire!
How many summers will it take? My guess is three consecutive summers….
This article: Doctors wasting over two thirds of their time doing paperwork showed up on Facebook yesterday.
The problem is that “hiring people to help with paperwork” will not help.
Why? We’ve already done that and it’s a huge mess.
For example: I was referred to an Ear Nose and Throat Specialist at one of the Seattle Mecca hospitals. I had to travel two hours and then in the waiting room I was given a four page patient history to fill out. I filled it out. I had been referred by a Neurologist, who sent a letter and note. After I filled out the forms, HIPAA and “you will pay if your stupid insurance won’t” and address and consent to be treated and yada yada…. I waited.
At last I was shown to a very luxurious room. There a medical assistant asked me many of the same questions that I’d filled out on the form and which were already in the letter and note from the neurologist. She typed these into the EMR- electronic medical record. Then she left. And I waited.
At last the distinguished otolaryngologist entered the room. He said, “I see that you are here for chronic sinus infections.”
“No.” I said. “I am not.”
“I see that you did not read anything I filled out and I am a physician and I drove two hours to see you.”
Silence. “Um.” he said. “Uh, why are you here?”
“Strep A sepsis twice and we want to know if my tonsils should be removed.”
Right. So… all that paper you fill out before the physician saw you? Yeah, like, my impression is that physicians don’t read it until after you leave. And maybe mostly don’t EVER read it.
I plan to find out the next time I have to see a specialist. I will write “you don’t read this anyhow, so I am not filling this shit out” on page 2 and see if the specialist notices. Bet you money they don’t. Though when they yell at their staff for not entering my medication allergies or the review of systems, they might notice.
So… I am a primary care physician. What do I do?
A new patient has one form: name, address, insurance information, hipaa and “you pay if your insurance doesn’t”.
I do the health history myself in the room entering it in the first visit, which takes 45 minutes to an hour. WHOA! INEFFICIENT! Nope. Actually it is brutally efficient. For four reasons:
One — I enter it myself and ask the questions myself and I am really fast at it.
Two — now I know the person, because I went over all of it: complaint, history of present illness, past medical history, social history, allergies, review of systems, and I ask people to bring all their pills including supplements to the first visit and I enter them too. And I look at the bottles. I don’t like vitamins with 6667% of the Recommended Dietary Allowance of any vitamin, lots of vitamins now have herbs in them too and I would not recommend taking cow thymus, labeled as bovine thymus.
Three — Now I don’t have to spend time reading forms filled out in the waiting room or a history entered by someone else, because I don’t have time to do that anyhow. I did it all in the visit. I will still have to read old records and any labs or xray results or consult notes or pathology reports and hey, where do you think the waiting room paperwork falls in that priority list? Yeah, like never.
Four — I hand people a copy of the note as they leave and ask them to read it and to bring corrections if I got it wrong. They go from thinking that I am a drone staring at the laptop to saying, “Hey, she typed nearly everything I said (and she has three spelling errors).”
Because the truth is that medicine is really complicated now and it just doesn’t help to have more people “do the paperwork”. I have to read the notes and labs and reports myself, because I am the physician.
There are three things that WOULD help:
1. One set of rules. Hello, the insurance companies, all 500ish of them send us postcards and emails every week saying “Hey, we’ve changed what we cover, meaning we cover less and we have new improved and more complicated prior authorization rules! Go to our website to read all about it.” Guess how often I have time to do that. NEVER NEVER NEVER. I read medicare’s rules. So medicare for all, single payer is partly to have ONE SET OF RULES. I can memorize miles of rules, but not if they are changing in 500 companies every week. Shell game. Also, prior authorization means “your insurance company is making your doctor fill out paperwork in hopes that they can delay or refuse the care your doctor thinks is best for you.”
2. One electronic medical record. Right now there are about 500 of them too and none of them talk to each other so we are all “paperless”. Ha. It’s worse than ever, because we get 100 pages or 200 or 300 of printed out electronic medical record for every single new patient. I need two more big file cabinets for my “paperless” office. Hong Kong did it in 9 months. What, are we wimps? Make a decision.
3. Standardization of lab and xray and home health and physical therapy and nursing home and rehab and hospital order forms. Because every stupid lab form is different: not only arranged differently but also the lab panels are different, the requirements for what that lab wants to fill the order is different and the results are arranged differently on the page. Hello. Stupid, right? Any efficiency expert would laugh.
And that’s how we could really help doctors help patients.
P for Phoenix, for the Blogging from A to Z Challenge. This post is for Amanuensis Sobriquet-Reverie. Her poem today “Burn the witch” brings up present and past difficult memories. Here is the poem I wrote about it in 2003.
Set a torch to me
Why don’t you?
It’s not the tearing sound of fabric
A small rip
And now a tear
That I feel
It’s the torch
I’ve been here before
A job where the idealistic came
As moths to the flame
Because they had ideals
I watched and burned and rose
It’s the torch
The flames that rise
As the witch is burned
Tilts back her head
In ecstasy and knowledge
Eager to learn what she can
From these burning brands
In the burning we learn
In pain we learn
If we can remain open
Ashes fall to the ground
Buckets of water
Wash any remains to grey mud
Relief for the frightened
An example has been set
No but what stirs at night
Moon or none
What rises from the mud
Set a torch to me
Why don’t you?
And see what is created
a local bookstore
previously published on everything2.com