A Country Doctor Writes:

“Team based care” is one of today’s buzzwords without real substance, because unless the payment systems change, only the physician members of the “team” can bill for their work.

Few people seem to be concerned with the simple but essential question of how physicians spend their time and how medical offices are paid. As a primary care physician who doesn't do any major procedures, and who in 2014 is essentially paid fee for service, I should bill around $400 per hour – $7 per minute, to put it bluntly – for my employer to stay afloat and for me and our support staff to stay employed.

Physician review and oversight of the team’s efforts, which is a medical and medicolegal necessity, is an unreimbursed activity. So, how much enthusiasm do the healthcare experts really expect to see for schemes that have computers, apps and non-physicians gather information for physicians to act on without seeing the patient – and thus, without the clinic collecting a fee?

But also, taking a medical history, for example, is not necessarily a simple task that can or should be delegated to team members with little or no training for it. Just like employers who interview prospective new employees themselves, or at least have a seasoned Human Resource professional do the job, doctors do more than just ask questions and record the answers. They pay attention to the person’s posture, attitude, facial expressions and willingness to provide the information.

Would a journalist have someone else interview a politician and then feel he could write a credible feature article based on the other person’s notes?

How truthful and accurate are the answers our patients give in the mandated depression screenings our medical assistants administer in our clinics? How many patients just barely even tell their doctor their innermost feelings and thoughts?

The reality in medicine is that the licensed professionals need to do the bulk of patient interacting and decision making, because that is what they are trained to do. Other team members need to be part of the process by preparing for visits, facilitating the plan that is outlined in the medical record, fielding questions and carrying out standing orders. I don't advocate for less involvement by support staff, but actually more. For example, I feel the front desk staff needs to know which patients and which types of symptoms require more time and which ones require less, in order to be able to schedule appointments intelligently and make the best use of physicians’ time. I also think each provider’s primary nurse or medical assistant should read all office notes after they are completed, so that if a patient calls back with a problem the medical assistant has an immediate awareness of how this patient can best be helped.

Similarly, if a patient is fit into the day’s schedule, a team member who reads the chart in order to make sure pending reports are available and who scans the phone messages and other things that have happened since the last visit can help the physician “hit the ground running”. Also, making sure at check-in that the patient doesn't have an immediate and different concern that may change the plan for the day avoids wasting everybody’s time in the visit.

Team members in a primary care office who know the patient and know what usually happens in typical situations are invaluable. Most primary care offices don't have team members with professional licenses that allow them to make clinical judgements, but just by being facilitators and advocates, they can easily double a physician’s productivity.

Which team effort moves the care forward most efficiently? Having medical assistants give depression screenings and smoking cessation counseling or making sure everything needed for the visit is available? Patients with urinary symptoms need to have a urine test, wound care visits must have all necessary supplies at hand and hospital follow-ups must have not only the discharge summary but also the consultations and all test results available, or the practice loses $7 for every minute of wasted physician time. It may seem mundane to today’s healthcare visionaries, but such efforts keep the doors open.

There is a strange cliché in use here, “working to the top of your license”. This has been used to justify letting support staff take over screening and education duties. It has not been applied to freeing physicians from clerical tasks like entering data that used to be done by transcriptionists.

I am not afraid to clean exam rooms after my visits are done, or anything else that keeps the office flow going. But I get a little frustrated when non-medical people opine that taking histories, doing physical assessments and counseling patients is so easy that anyone can do it. Sure, I can wire a three-way light switch and solder a copper pipe, but electricians and plumbers do it better, faster and neater. That isn't something for me to be embarrassed about – they have more experience doing it, just like I have more experience taking medical histories than nurses and medical assistants, because it is what I do for a living.

I do support making use of special talents; we once had a medical assistant who was a natural motivator. She took courses in motivational interviewing and became our smoking cessation counselor. But a blindly applied “working to the top of your license” is also known as “the Peter principle” – push everyone to their limit, where they can no longer do what is asked of them.

I don't know if I am just less aware of this in other “industries”, or if this is something unique to non-medical policymakers’ vision of medicine: There is less and less respect for professional training, skill and experience. If this were declared as a social experiment or an “equalization” effort, I would understand (after all, I grew up and trained in a Socialist country), but that is not quite what I hear.

My next topic in this series will be doctors, nurses and nurse practitioners – who should do what?