Right before my hospital district informed me that they no longer wanted my services, I was rebelling. The fight from my perspective, was over good patient care. They had set a quota. 18 patients a day. One every 20 minutes and one 40 minute visit. 8 am to noon and 1 pm to 5. I argued and argued and argued. I knew finishing the note in the room took me 25 minutes on the hateful electronic medical record and I had averaged 16 patients a day my whole career. I was not fast but I was super thorough and had just gotten an excellent report on a chart review and had been told that I was a great diagnostician. Which was mostly due to my nearly OCD thoroughness. I was not diplomatic with the hospital administration.
One day I was feeling wicked, just wicked. I had a brainstorm and started whistling softly. The other two doctors and PA were all in the same small office.
One took the bait. “What is that? I know that song.”
“Oh, we are singing it in chorus. For some reason it is in my head today.” So I sang this song.
I did not have the words memorized. I swear that the temperature in the room dropped and the male doctors hunched in their chairs.
“Yeah, don’t know why that one keeps playing in my head.” I said. “I hope you can all come to the concert!”
But answer came there none.
I took the photograph at Quimper Family Medicine, the clinic I opened after the hospital clinic kicked me out. The skeleton was named Mordechai in a contest. This is from 2014. Mordechai lived in our waiting room every October, with different outfits.
In Practicing conflict, I wrote about practicing conflict by arguing different sides of a topic inside my head. I wrote that I don’t fear conflict and have learned to enjoy arguing with myself. I am a physician and physicians argue all the time.
What? No they don’t. Well, the doctor persona does not argue with the patient much. Some doctors give orders to patients, others try to negotiate, some try to convince. But behind the scenes, doctors are more like the Whacky Racer Car with the Cave Guys, running with their feet and hitting each other with clubs.
In residency in Family Practice at OHSU in Portland, Oregon, I start on General Surgery during internship. This is in the early 1990s and there was not much in the way of “disruptive physician” rules. I have to cover Trauma and Plastic Surgery and General Surgery at night on call. The resident is present but I get paged first for patients on the floor. I learn that I should go to all Trauma pages in the emergency room. If I know what is happening with the new Trauma patient, it’s a lot easier to handle the phone calls for more drugs and so forth. Also, the resident is less mean to me.
We attend the Trauma “Grand Rounds”. These are unreassuring to a new intern. A resident presents a trauma patient, giving the history in the accepted formal order. The Faculty Trauma Surgeons interrupt, disagree with management of the patient and yell. They yell at the resident and at each other. The upper level residents yell too, being well trained. The Trauma Surgeons do not agree with each other. They are inflammatory and rude. I am shocked initially: medicine is not a cookbook, is not simple and it appears that it is a controversial mess. It turns out that medicine IS a controversial mess.
There is not as much yelling on the next rotation. At that time Trauma Surgeons yelled more than any other set of doctors that I ran across. They yelled in the ER, at each other, at the staff, at the nurses, at the residents. The culture has changed, I suspect, but that’s how it was then.
I take Advanced Trauma Life Support as a third year resident. The Trauma Surgeons at OHSU helped write the course. They don’t agree with it. On some questions the teaching Surgeon says, “The answer to this question is (c), “ followed by muttering loudly, “though I totally don’t agree with that and I would do (b).” Another Trauma resident or surgeon then might start arguing with him, but they moved on pretty quickly, to teach the current agreed best practices in the book. Which change every few years. Great.
Years later (2009) I join the Mad as Hell Doctors, to go across the US talking about single payer. They are a group from Oregon. Physicians for a National Healthcare Program are a bit cautious with us the first year: we might be whackos. We have an RV with our logo and we have a small fleet of cars and what do you think we do in the cars? We argue. Or discuss. Or whatever you want to call it. We spend the driving dissecting issues and how to present things best and tearing apart the last presentation and rebuilding our ideas. The group does 36 presentations in 24 days. Each presentation takes an hour to set up, two hours to do and another hour to break down and debrief. We get more and more exhausted and cranky and um, well, argumentative, as the trip proceeds. Even though I think of the Whacky Racer Cave Guys running with their feet and bonking each other with clubs, this is the most wonderful group of doctors I have ever been with. A common goal that we all want to get to, discussing and disagreeing on strategy all the way! I feel closer to those physicians in a week then I feel to any of the physicians that I’ve worked with for the last 9 years in my small town. Conflict with a common goal.
Doctors are TRAINED to argue, even with themselves, to document every decision in the chart with reasons why they have reached that decision. And that they have thought about all of the reasons for say, a low potassium, thought of every possible cause and worked their way through testing. The testing always has two strands. One strand is rule out the things that could kill the person NOW, even if rare. The other strand is what is common? You have to think about both at the same time, always. And argue with yourself about which tests should be done, in what order, what is most important, how do you treat the person while awaiting results, and have I missed anything? And if we aren’t sure, we call another doctor, run it by them, wait for them to shoot holes in our logic or to say, no, I can’t think of anything else.
We can deal with conflict. We must deal with conflict. The world is too small not to deal with conflict, with disagreements, with different viewpoints and positions and ideas. If doctors can do it every single day at work, then everyone else can too. Trying to see all the positions and possible diagnoses saves lives in medicine. We need to extrapolate that to everything else. Try to see other positions, try to understand them, to respect them. We can and we must.
I had a small one doc family practice clinic for ten years. Spent more time with patients. The trade off was that if they need a prior authorization, they had to come in for a visit. I would call the insurance company from the room face to face counselling and coordination of care and all that crap. This did a number of things:
1. I could bill for the time.
2. The patient saw how the insurance company treats us and our offices. The rep on the line would try to call me by my first name since doctors rarely call. I would say, “No, please call me Dr. Ottaway.”
3. The patients sometimes had called their insurances already and been told “Have your doctor call.” When I would call, the company rep would sometimes say, “We don’t cover that.” The patient would be outraged and say, “But I called YESTERDAY.” The rep would say, “I only talk to doctors. The part of the company that talks to patients is a different part.” The insurance companies can’t triangulate their way out of that.
4. I would end the call by saying, “This has been a face to face with the patient call, you have been on speaker phone and I am documenting the call and the time in the patient’s chart.” At first the calls took 25-30 minutes. Some companies apparently flagged me, and would say “Yes.” if I called, and get me off the phone as fast as possible. They really do not like it being documented in the chart.
5. Insurance companies sometimes drop patients on purpose because the person has gotten more expensive. I had a snow bird from Alaska whose insurance had dropped him. He said he’d paid on time. I said, come in if you want and I will call them. I spent 45 minutes on the phone where they made multiple excuses, lied (we can’t send you a copy of his insurance because we don’t have a fax after they’d said he was not allowed to leave Alaska and I said, “For how long? What do you mean? You don’t insure him if he’s out of the state? Send me a copy of his insurance contract!”) I finally realize that they have dropped him on purpose because he’s been diagnosed with diabetes. I say “Ok, look, I am staying on the phone until he’s reinstated and I don’t care how long it takes. And if you hang up on me I will contact the insurance commissioner in Alaska and Washington states.”
6. Patients are truly outraged at how a physician is treated when she calls an insurance company herself. I have to give my name, my NPI number, my address, my phone number, my fax number, the patient name, the patient address, the patient phone number the patient insurance number and sometimes have to do it every time someone transfers me. When they see me spend 25-30 minutes on the phone to get a prior auth, especially if it is refused, they are up in arms.
I think it would be truly revolutionary if every doc in the country called an insurance company with a patient in the room and documented the conversation in the chart. Wouldn’t that be fun?
This is not my forte. I was raised by pack rats and I have genes from both sides. My OCD tendencies are confined to patient charts and keeping shoes in their original shoe boxes. Otherwise my house is piler pack rat. Piler, not filer. Filing is boring. My office managers have to be Queen Filers to keep me in line. Both of them were, too.
Cleaning out the clinic was difficult. I found stuff I didn’t know I had, of course. What to do with the metal speculums? Keep for posterity or in case we run out of oil? I don’t actually know where the speculums went, they went off with a friend who is helping.
In retrospect, I think my mother would have made paper mache ducks with speculums as beaks and wish I’d kept one. Ah, well.
Someone bought the weird shelves. The microwave’s owner picked it up. We had three printers running at any one time except when one would die and we’d only have two. This printer went home with me. New and old computers went home with me because one has to wreck the hard drive because HIPAA. My house currently looks like a computer/printer/scanner/file cabinet graveyard. It’s annoying.
Besides this messy room, there are also 8-10 more boxes of stuff moved down to the basement. I have to keep patient charts for ten years or until they are 21 for minors. I have paid a company Big Bucks to take that over. I have to keep business records for 7-10 years depending on if it’s state or feds.
Well, I’ll sort it before I’m dead, or else my kids will.
The contact information for billing is by mail only:
Quimper Family Medicine
PO Box 1053
Port Townsend, WA 98368
I had the fax number set up to fax to the cloud, but Century Link botched it massively. I spent an hour on the phone with them a week ago Thursday and couldn’t fix it. Good it wasn’t in person, because I wanted to break things. They screwed up the change of address, didn’t send me a bill, didn’t sent me the email to activate the damn thing, then passed me off to someone else who hung up on me. My thoughts about Century Link currently are quite dark and not publishable on a family friendly blog.
I miss my peeps. You people, friends and patients.
In October, Mordechai the plastic skeleton hangs out in the Quimper Family Medicine waiting room. She changes outfits. We had a 10 year old visitor who rearranged everything and now Mordechai is on fleek. She is holding out emergency preparedness pamphlets.
Mordechai, the Quimper Family Medicine genuine plastic skeleton, came out to dinner with us on Saturday and seemed to have a great time. She is wearing a sequinned top, though you can still see her ribs through it. Lots of people stopped by to get introduced….
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?
returning phone calls
doing refills. To do a refill I check when the patient was last seen and whether they are due for laboratory.
reading specialist notes and updating medicine lists, diagnoses and contacting patients to get tests or follow up that the specialist has recommended
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
reading emergency room notes and hospital discharge summaries and setting those patients up for follow up, updating medicine lists and adding to diagnosis lists.
dealing with multiple stupid letters from insurance companies questioning the medication that I have prescribed. Mostly I mail these to patients.
running my small business: long term planning, short term planning, advertising, commercial insurance
50 hours of continuing medical education yearly
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.
Worrying about small business costs as reimbursement costs drop: health insurance. Retirement. L&I. Employees. Malpractice insurance, small business insurance, the lease, staff costs.
Discussing and updating medical supplies and equipment, office supplies and equipment
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.
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.
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.
I change the art at clinic, these for the summer. We had four reproductions up before, of alchemy paintings from the 1400-1600s. I thought they were creepy but also interesting and beautiful.
The painting on the left is by my mother, Helen Burling Ottaway, of my sister, Christine Robbins Ottaway. On the right is an oil by an artist that I don’t know. It looks like my father. I inherited art, but I keep finding beautiful pieces. At least I can display a little and rotate them with the seasons…
Refugees welcome - Flüchtlinge willkommen I am teaching German to refugees. Ich unterrichte geflüchtete Menschen in der deutschen Sprache. I am writing this blog in English and German because my friends speak English and German. Ich schreibe auf Deutsch und Englisch, weil meine Freunde Deutsch und Englisch sprechen.
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