It’s Time We Talk About Who Should Do What in Healthcare Teams


“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?

5 Responses to “It’s Time We Talk About Who Should Do What in Healthcare Teams”

  1. 1 pat kelly October 1, 2014 at 8:02 pm

    Actually over 50% of primary care offices now have NPs and PAs, so they do have licensed medical professionals who can bill (at least 85% of the Medicare rate) for all visits and engage in medical decision making, diagnosis, and treatment.

    • 2 acountrydoctorwrites October 1, 2014 at 11:48 pm

      I was referring to providers as well as nurses, case managers and others who cannot bill for their services. Their salaries are paid from grants (FQHCs) and/or revenues from physician, NP or PA visits.

      • 3 patricia kelly October 9, 2014 at 6:33 pm

        Agree!!!!! I know a FQHC with only three providers and about twenty administrative types! Upside down, it seems.

  2. 4 Andrew_M_Garland October 2, 2014 at 5:04 am

    Country Doctor: “If this were declared as a social experiment or an “equalization” effort, I would understand.”

    Yes, it is a social experiment. The government is attractive to people who believe they can do everything better than the people in every profession.

    Obama has stated that he is better at everything than the people around him. All he lacks is enough time to do it all. Progressives, especially academicians, believe that being a doctor is only a matter of memorizing the right checklist. So why not prescribe from on high and automate?

    Many Liberals believe that all human activity is a social construct. People are directed by “society” to be a laborer, or a mathematician, a doctor, or something else. Assuming this amazing irrationality, it then follows by pure reason (eyes closed) to require that the discriminatory institutions of society correct their unequal assignments. They need only the will to produce workers of all types and abilities in proportion to the central, government plan.

    Karl Marx on Social Identity
    ( )
    === ===
    In a communist society, where no one has one exclusive sphere of activity but each can become accomplished in any branch he wishes, society regulates the general production and thus makes it possible for me to do one thing today and another tomorrow, to hunt in the morning, fish in the afternoon, rear cattle in the evening, criticise after dinner, just as I have a mind, without ever becoming hunter, fisherman, herdsman or critic.
    === ===

    This is one message of Occupy Wall Street. We went to school, now where are our careers? Why do we need to do one thing rather than another? It is pure Marx, a philosopher who proposed rules for a world which doesn’t exist.

    The Solution Is Simple

    Dunning-Kruger effect: The hubris of the incompetent.
    Quip: I could do that better than you, if I wanted to.
    === ===
    Wikipedia [edited]: The Dunning–Kruger effect is a bias in thinking. People may make bad choices, and be incompetent to realize it.

    The unskilled overrate their own ability as above average. The highly-skilled underrate their abilities, often below the self-rating of the unskilled.
    === ===

    A large fraction, maybe a majority, see unequal incomes as undeserved. The less competent think they are only unlucky. Amazingly, many of the more competent don’t see their work as so difficult as to deserve their high salaries, and they want to transfer their guilt.

    This is reinforced by the impossible promises made by Progressives to deliver more healthcare at less cost to people who have “already paid” their taxes for those promises. Our rulers think that they can deliver on those promises if they convert medicine to a database lookup.

    Why do they think they can do this? Because, how hard could it be? Medicine doesn’t look very complicated to them.

  3. 5 Sterling Haws November 11, 2014 at 4:32 am

    I really enjoyed this post. Thank you for your faithfulness and integrity in writing.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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