Tag Archives: burnout

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Doctors are leaving medicine

https://www.healthgrades.com/pro/7-reasons-doctors-are-leaving-medicine?CID=64embrdTINL120523

Ok, reason number five: “One study finds doctors spend two hours on EHR record-keeping for every single hour in clinical contact with patients. EHR dissatisfaction has been linked to higher burnout scores, and burnout can lead doctors to leave clinical practice or quit medicine altogether.”

Back in 2009 I argued with my employer about their policy. They had put us all to 20 minute visits, one 40 minute one a day, and continuous visits 8-noon and 1 to 5. Also, they had daily meetings from noon to 1. Full time was four eight hour days, except they are nine hours with the meetings. I said, “Look, one day of clinic generates at least two hours of work: reading lab results, reading radiology reports, calling patients, calling specialists, dealing with insurance, dealing with phone calls, refills, patient requests, calling pharmacies. So four 8 hour clinic days generates another 8 hours minimum of work, plus I have call nights, plus those four hours of meetings every weeks, so I am working 44 hours of week minimum and with call I can hit 60-80 hours in a week.” The administration did not care. I promptly cut to 3.5 patient days. They initially said, “You can only do 3 or 4 days, not 3.5.” I said, “Why?” They said it was not the most efficient use of clinic space. I said, “You don’t have anyone to put in for the full day, so using it for a half day generates more income than having it empty.” They reluctantly agreed.

I could finish a clinic EMR (electronic medical record) note in the room with the patient in 25 minutes but not 20, during the visit. The administration and computer loving doctors had said, this system is to let you finish the note in the room. It took me three years to be able to consistently do that in 25 minutes. Many providers were allowing their home computer to access the system. This meant they were working after hours at home after everyone else was asleep or on weekend morning. I refused to have it at home. I came into clinic at 5 am to do the work, since then I wouldn’t get interrupted, but I wanted home to be home. Also, I live four blocks from that employer.

I decided that I was sticking with finishing the notes in the room. I ran late. I apologized to patients, saying that the hospital was now requiring a quota of 18 patients a day and that I disagreed with it. I tried to convince the administration that I needed more time and help, but they dispensed with me.

Two years later another physician quit medicine and the hospital dropped the quota to 16 patients a day.

So it makes me laugh to see that it says in that article that eight hours of clinic generates sixteen hours of “EMR work”. The implication is often that it is busywork but much of it is NOT busywork. I have to read the xray report and decide what to do with it. Same for every lab. Same for the specialist letter. Same for physical therapy, respiratory therapy, home health, hospice, occupational therapy, notes from psychology or psychiatry, notes from the hospitalization here or elsewhere. Read, decide if I need to do anything, update the EMR? Sign the document off. Decide, decide, decide and get it right. Call the patient or a letter or call a specialist or ask my partner for a second set of brains, am I missing something? This is all WORK.

At one point a clinic shut down in three counties. My clinic (post hospital) took a new patient daily for months. We couldn’t get the notes so we had to look at med lists, get history from the patients and wing it. Or get hospital records labs xrays specialist notes. Yep. Nearly every patient had “deferred maintenance”: they were behind on colonoscopy, mammogram, labs, specialist visit, echocardiogram. We ordered and ordered. Then we had to deal with all the results! After about five months I say to my receptionist, “I’m TIRED.” She was too. We dropped to three new patients a week. Then two. Then one.

I also spent an hour with new patients and my visits were 30 minutes. I was the administrator of my clinic too, and pointed out to the physician (me) that we were not making much money. With 30 minutes I could look at things during the visit and explain results and get much of it, but not all, done.

So if a 20 minute clinic visit generates 40 more minutes of work, in labs, reviewing old records, reading specialist notes, reading about a new medical problem, keeping up on continuing medical education, reading xray reports, echocardiograms, writing letters for jury duty exclusion, sports physicals, disability paperwork, sleep apnea equipment, oxygen equipment, cardiac rehab reports and orders,etc, then how many patients would give us a forty hour week? At one hour per patient, that is 40 patients a week, right? 18 patients daily for 4 days is 72 per week and that is not including the on call or obstetrics done at night and on the weekend. 72 patients would generate another 144 hours of work according to that article which is untenable. 36 hours+144 hours+call = over 180 hours weekly. And so I am not surprised at the levels of burnout and people quitting.

We have to value the actual work of not only “seeing a patient” but “thinking about the patient, reading about a disorder, reading all of the notes and test results and specialist notes”. Isn’t that what we want, someone who will really spend the time and think?

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Fraud in medicine: why “help” won’t help

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.”

Silence.

“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.