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Double-Booking the Doctor is Half-Booking the Patient

Not only have we shortened medical appointments to 15 minutes. We also sometimes double book them.

I get the feeling that non-providers think of this as something fairly ordinary, and even reasonable. But it is often a very difficult and destructive thing to do.

The term “double booking” and the way it looks in an ordinary doctor’s scheduling grid suggest that the physician might possibly be expected to be in two places at the same time. That is hardly ever the case for those of us who are mere mortals.

Sometimes a patient does need a lot of non-provider time, for example to get undressed and ready for a Pap smear. In such a case the doctor could take a quick look at another patient’s sutures or something simple like that in another exam room while the first patient is getting ready.

There is a tendency to squeeze in simple things almost anywhere, but, depending on who is losing half of their fifteen minute appointment, that might be a very unkind thing to do. In today’s reality, with Meaningful Use, ACOs and Patient Centered Medical Homes, we have to screen for various conditions and risk factors, update medication lists, immunizations and family and social history in every single visit. There really are no in-and-out quick visits anymore, thanks to our well meaning(?) Government.

In small practices, where the scheduler knows patients really well, it might be possible to predict better whose visit will be short and whose will take more time. But we have found as we have grown that this kind of knowledge is disappearing a little, and in some computer programs, the scheduling grid doesn’t show the names or concerns of scheduled patients, just that a slot is already filled.

This is why, the other day, somebody else got double booked with an elderly patient of mine who was given only a fifteen minute appointment for depression.

Double booking is sometimes used as a strategy to manage no-shows. That can be really bad.

In some practices, patients who have no-showed too many times are double booked with another patient, so that the expensive doctor doesn’t risk being idle for fifteen minutes. Of course, if the habitual no-show patient does make it to the appointment, the doctor is faced with managing both the catch-up of a patient who may be well overdue for whatever they came in for and the compromised visit of another unsuspecting patient. That unfortunate person ends up paying the consequences of having another patient booked in the same time slot. Two players in this triangle pay the price of the past transgressions of the third.

There is no good solution for no-shows. Dismissing such patients may seem easy for the practice, but even if you don’t believe health care is everybody’s right, some people no-show because of their economic or social situations and really need to be seen when they are finally able to keep an appointment, for example a child who is behind on immunizations.

The double booking due to being busy needs to be looked at in a humane and business-like way, and it needs the direction of the medical provider: The random double booking of unmarked squares on a computer screen is no better than throwing darts. We need to analyze our data to better predict the demand for services on a Monday morning or Friday afternoon before a long weekend.

And we need to risk a provider sometimes having fifteen unscheduled minutes. That time could be spent on patient relations or care coordination. Because doctors aren’t just faceless widget makers who produce visits. We are the ambassadors and medical leaders, or brains, if you will, of our practices.

EMRs, PCMH and OCD are Limiting Access to Care

We have a problem in our clinic.

Between our EMR implementation a few years ago and our PCMH recognition shortly after that, our office visit documentation has become bloated and our cycle time has almost doubled.

There are no brief visits anymore, since every visit entails screening for multiple psychosocial conditions and consideration of various immunization and health maintenance reminders.

Nobody sees over thirty patients a day anymore; we’re lucky to exceed twenty.

That means patients today are actually more likely to go to walk-in clinics or emergency rooms than they were a few decades ago. We’re still okay with PCMH as long as we have a single open access slot at the beginning of every day, and we don’t actually get any credit for squeezing in, or double booking, acutes.

It also means patients with chronic illnesses get seen a little less often than they used to. Sure, we have RN case managers who can stay in touch with them, but the communication between them and the medical providers is hampered by the new busyness of checking our electronic inboxes, which takes seconds longer for each item than the old paper reports used to take, and which is done “in between patients” in our already tight schedules or after hours, staying late at the clinic or logging in from home.

It wasn’t supposed to be this way.

Here is what we hoped and were led to believe would happen:

1) EMRs were supposed to make documentation lightning fast.
2) EMRs were supposed to make data review and retrieval faster than paper systems.
3) PCMH would have us transform into physician driven, super-efficient, yet warm-and-fuzzy places filled with patient friendly personal touches.

Instead, medical practices have evolved into bigger bureaucracies with OCD afflicted doctors who don’t lead practice transformation, but who feel personally responsible to compensate for all the shortcomings of their hastily implemented, immature technology.

OCD may be the most significant and destructive acronym in today’s healthcare environment. And we have all been cultivating it, medical practices and providers alike.

The old school expression of OCD, in Marcus Welby’s era, was extremely high physician productivity and unwavering personal commitment to patients.

The new manifestation of OCD is trying to follow overly ambitious, often conflicting Federal edicts and mind-melding ourselves with our computers to the point of losing touch with our patients’ real needs.

Why else did we end up with a working environment where we allow ourselves to be distracted by health maintenance discussions when somebody comes into see us for what should be a ten minute visit for a simple sore throat, or when they are in pain from an injury?

(A ten minute oil change for your car is not the same as a 100,000 mile service, is it? Why is health care any different?)

Why else do we think that it is appropriate to do depression, alcohol, smoking, domestic and drug abuse screenings on new patients the minute they walk through the door to size us up as their chosen new health care provider?

(How did it become patient centered not to spend the first visit, or even the first few minutes of a new therapeutic relationship, listening to the concerns of a new patient?)

Why else, if not because of our personal and organizational OCD, are we sending our own patients to the walk-in clinic instead of fitting them into our own schedules? Isn’t it because of our obsessive fear that we might document such a quick visit without the required Federal accoutrements and end up scoring poorly on some arbitrary quality scale?

(Do we really think the walk-in clinic will do a better medication reconciliation than we do if we squeeze a 45 year old hypertensive diabetic in for quick look at an ankle sprain?)

Pardon my comparison to veterinary medicine, but in my veterinarian’s cash practice, they manage their health maintenance reminders by simply printing them automatically on the receipt. If I bring a pet in for something simple, they don’t bloat the visit up by talking about things I didn’t come in for; they stay on schedule and I can read the printed reminders at my leisure.

Somehow, in the new vision of primary care, we went from taking care of our patients over a continuum of time to doing everything all at once, as if there were never going to be other visits. That kind of OCD is anathema to real primary care.

And somewhere along the path to more patient-centeredness, we got sidetracked by the paternalistic ambitions of our biggest payer, Medicare, into hammering our customers with Federally imposed public health agendas that have little to do which their personal vision of why they need a doctor.

To quote a new patient who came in to size me up a few years ago:

“I need a doctor when I’m sick.”

Access, in other words.

From Learned Professionals to Skilled Workers: The Dangerous De-professionalization of Medicine

Physicians today are increasingly viewed and treated as skilled workers instead of professionals. The difference is fundamental, and lies at the root of today’s epidemic of physician burnout.

Historically, there have been three Learned Professions: Law, Medicine and Theology. These were occupations associated with extensive learning, regulation by associations of their peers, and adherence to strong ethical principles, providing objective counsel and service for others.

Learned Professionals have, over many centuries, worked independently in applying their knowledge of Law, Theology or Medicine to the unique situations presented by those who seek their services. They have done this work with a significant freedom that has been balanced by their commitment to the fundamentals of their disciplines and responsibility to their professional corps. They have answered to their clients, their profession and to the legal system of their countries, perhaps with the exception of where the Church has defied or resisted Government.

Skilled workers are different from Learned Professionals in that they, although their work may be highly complex, don’t independently interpret the theories behind what they do, but instead follow strict protocols and orders from supervisors. Examples of skilled workers are nuclear reactor operators, commercial jet pilots and Certified Public Accountants. No matter how much skill we require from nuclear reactor operators, for example, everybody sleeps better at night if they always follow their protocols and we assume that there are protocols for every imaginable scenario.

This is how many people, and particularly those who are now in roles of administration and finance in Government and the healthcare “industry”, have come to view Medicine; they think it is too important a job to trust individual providers to do well in without lots of supervision and protocols even more detailed than those in the nuclear or airline industries.

A few, narrow, specialties in Medicine and probably also in Law and Theology, might lend themselves to closer comparison with running a nuclear plant or flying passenger jets, but the definition of the Learned Professions is that they deal with not only complexity of but also with the uncertainty caused by the infinite human variation in expression of their science.

The narrower areas of Medicine, like joint replacement surgery, have tempted many to compare Medicine with manufacturing, for example. But even joint replacement surgery requires a level of judgement that goes far beyond the manufacturing paradigm, beginning with making the assessment, in collaboration with the patient, whether joint replacement is even indicated and safe for the individual in the first place.

The management of everyday conditions like diabetes, hypertension, depression and abdominal pain requires solid scientific knowledge, yet also involves high degrees of uncertainty and complex decision-making with infinite variables to consider. In other words, to think these conditions can safely be managed by protocols is naive; “guidelines” in Medicine are only broad brush strokes of the general principles we follow or at least consider, but would be detrimental to countless patients if actually followed as if they were protocols.

The argument has been made that Medical Science has grown so exponentially that individual doctors can never stay informed enough to make independent judgments about patient care. Logic dictates that this explosion requires even more independent judgments, because it is simply not possible to develop “protocols” for everything. Anyone can see that a patient with four or five conditions will have issues where what is done for one condition has a negative impact on another, for example. We face this issue in almost every patient encounter.

The other day, I had to prescribe an antibiotic for a patient with a serious blood clotting problem. The antibiotic I thought of using could interfere with my patient’s blood thinner, and the ones that don’t interfere are less effective. There are no protocols for that.

The same day I talked with a student about the risk of serotonin syndrome when you co-administer certain medications. For example, modern antidepressants and common migraine medications could theoretically cause this syndrome. My student had read it in a textbook and our computerized databases warn us every time that prescribing them both may not be a good idea. The literature reports this interaction to be rare enough that major headache societies support using the combination with common sense precautions when both medications are indicated. Making that judgment in individual cases requires knowledge of the drugs, understanding of the patient’s condition, and awareness of the current literature, because textbooks quickly become outdated.

I also talked with my student about the new study that suggests that more aggressive blood pressure targets for treatment of hypertension than the JNC 8 “guideline” are associated with lower rates of cardiovascular events. Which number should one strive for – in a high risk middle aged patient, and in a frail, elderly, patient?

This is why Medicine should still be classified as a Learned Profession. And this is why doctors must hone and honor their scientific knowledge and critical thinking. And this is also why patients, who can get any isolated piece of fact they would ever want from the Internet, still need us as trusted guides, whose understanding of Medicine runs deeper than sound bytes, blog posts, news flashes – and “guidelines”.

35 Years of Burnout

One of the most prominent definitions describes burnout “as a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with people in some capacity“. (Maslach, Jackson & Leiter, 1996)

In 1974, the year I started medical school back in Sweden, the German-born American psychologist Herbert Freudenberger published a journal article titled “Staff burn-out”. In it, he wrote about the physical and emotional symptoms of burnout, and he described how cognition, judgment and emotions are affected.

In 1980, while I was working in Sweden’s socialized health care system, Freudenberger wrote his book “Burn Out: The High Cost of High Achievement. What it is and how to survive it”.

In 1981, the year I landed on these shores, Christine Maslach published “The measurement of experienced burnout”, with the Maslach Burnout Inventory, which seems to be the standard tool for quantifying this condition, which was first associated with high stress positions in the service sector. It was seen as related to serving the needs of very needy or complex clients with limited resources at one’s disposal.

Early literature on burnout among physicians focused on physicians in pediatric intensive care units, and later on emergency physicians. Today, burnout is discussed in every specialty. It is described as an epidemic that is threatening the continued contribution to our health care system by half of all practicing physicians.

I never heard much about burnout as a resident, young family doctor or even in my early middle age. Now, there is even an ICD-10 diagnostic code for burnout – Z73.0!

The other day, I listened to a podcast by Richard Swenson, MD. He makes the argument that burnout is linked to having too little margin in life. As I listened and tried to imagine which doctors I knew who may have risked burnout from lack of margin, I could only think of a half dozen private practice doctors I knew when I was a resident. The margin theory seems to me to apply mostly to Marcus Welby’s generation of physicians, who did what they loved to do, and although they were in nearly full control of their day, they allowed their professional sense of duty to infringe on their margins, in Swenson’s words, to stretch their physical and perhaps sometimes also their emotional energy to or even beyond their limit.

I believe today’s epidemic of physician burnout is often unrelated to our margins, but in many cases the result of not being in quite the right position or career situation:

I have written before about the “counterintuitive concept of burnout skills” – the “talents” we possess that often draw us into vicious cycles of self-sacrificing heroics to overcome the unfixable limitations of our individual jobs or of the healthcare systems we work within.

In that context, the antidote to burnout is developing and using the talents that bring us the greatest personal satisfaction. When we use those talents, we become energized, and our work becomes fulfilling and rewarding.

In medicine, that switch to what energizes us might be focusing more on mentoring or education, developing a niche of deeper knowledge and greater expertise in an area that we can feel passionate about, or perhaps serving a special needs population of patients, like deaf, immigrant or mentally challenged patients.

But, sadly, burnout in medicine today is increasingly caused by the relentless shift in the demands of physicians’ time, attention and and energy away from serving patients to also, and with no extra time alotted, fulfilling an increasing number of official mandates.

This dichotomy between what we trained for, treating the sick, and what we never imagined doing, inputting data for only remotely patient-centered purposes, is making physicians feel powerless, and that is the driver of today’s epidemic of burnout.

This burnout is different from the other two kinds in that it is unrelated to individual choices or character traits. It is not a “condition” among physicians as much as it is a consequence of the “working conditions” in today’s American health care. It is a direct consequence of what I call the de-professionalization of medicine.

With every passing year, it drives employed physicians in greater and greater numbers toward a desire to quit medicine altogether. Short of becoming self-employed entrepreneurs in their mid- or late career, they see no escape from the shift in emphasis away from patient-focused and to toward data-driven care. All practices, except cash-only ones, must devote increasing resources to collecting data and documenting compliance with mechanistic actions that often seem irrelevant to patients, who all have their own priorities for their fifteen minutes with their doctor.

The solution to, or cure of, physician burnout is obvious and easy, but not on anyone’s political agenda.

Suddenly Expensive Generics

Fran Barker called today. She was in a panic because the cost of her monthly prescription of 150 mg amitriptyline tablets had gone up to $130 from $13 the month before.

Amitriptyline has been available in this country since 1961, and the 100 mg strength was on Walmart’s list of $4/month drugs the last time I looked at it a few months ago.

I called Fran’s pharmacy. Two of the 75 mg tablets would be less expensive, about $75 for a one month supply, but this would still be a hardship for Fran, who is disabled and lacks prescription coverage.

A few months ago I read that the older, generic statin drugs for cholesterol were suddenly not on Walmart’s $4 list due to sudden price increases by the manufacturers.

Something similar happened to insulin a few years ago – it went from a few dollars to $80 per vial without any explanation that I was aware of.

I have Googled around a few times to try to find out what is happening, or what people think is happening, but the dramatic price increases I have run into don’t seem to be getting much press.

It appears to me that the pharmaceutical companies have stopped their price competition, possibly by secretly dividing up the market and definitely by limiting supplies. If that is true, antitrust laws are likely being broken. Meanwhile, people with chronic illnesses are being squeezed financially even more than they already have been.

Generic drugs used to be a low margin product for manufacturers, but a major profit for drug stores. With newer generics, whose brand name competitors are still on the market, pharmacies may buy them for 10% of what they pay for the brand and sell them for 70% of the brand name price. Now, with their purchase prices going up on one generic after another, their markup is likely shrinking to the levels of brand name drugs. This will likely drive independent pharmacies out of business.

We already had a great deal of mystery and intrigue around pharmaceutical pricing and actual insurance payments for prescription drugs. Just like doctors and patients have trouble figuring out how much MRIs and artificial knee joints cost, the real cost of pharmaceuticals is often unobtainable. I can try to choose lower cost medications by looking up the average retail cost on Epocrates, but insurance companies and drug manufacturers often negotiate deals that make favored otherwise expensive drugs cost less than non-favored drugs with lower published prices.

This whole drug price situation is really the stuff of mobster movies. Or imagine a sitcom about what happens when gasoline (petrol) prices increase by 900% overnight. That wouldn’t be funny for very long. People would complain loudly about being held hostage or extorted.

But is anybody complaining about what is happening now with drug prices? Am I just not hearing about it because I gave up watching TV? Or am I an early voice in the wilderness? You tell me…

How Should Doctors Get Paid? – Part 4

Honest Pay for Honest Work

Times have changed. And it’s time they change again.

In the past, medical care was more episodic than it is now. People went to see the doctor when they felt unwell. Diabetes affected mostly older patients, who didn’t live long enough with the disease to develop complications. There were no blockbuster drugs for high cholesterol, Hepatitis C, fibromyalgia or chronic heartburn; we didn’t manage nearly as many patients on multiple medications as we do now.

In those times, a payment scale based on the length and complexity of the visit made sense, and there wasn’t much doctor-patient interaction between visits.

Today, we manage more chronic conditions, use more medications, do more laboratory monitoring, more patient education, and more administrative work on behalf of our patients than before.

Payment scales based only on what we do in the face-to-face visit have become hopelessly antiquated and stand in the way of the new demands of society – physicians providing longitudinal care for chronic conditions in patient-centered medical homes.

The business reality of primary care is that a doctor in a group practice needs to bring in $400/hour to keep the doors open and the support staff available to do the clinical and administrative work. Insurance billing and waiting to be paid is costly and requires cash on hand. Electronic medical records are expensive to install and maintain.

Insurance payments for face-to-face visits are arbitrarily “discounted”, yet expectations are increasing for providers to render additional services after or between visits. In many cases the extra work is generated by the insurance company:

A new prescription requires a “prior authorization”, but many insurers are secretive about what drugs must be tried before the desired drug will be approved (only a handful of insurers post their preferred drug lists on Epocrates, the central repository physicians can access on their smartphones);

A “pharmacy benefit manager” contacts a doctor to suggest that his diabetic patient should be on an ACE inhibitor or a statin, when the patient is actually already taking them. He pays cash at Wal-Mart because that is less costly than the insurance copayment at the local drugstore, so these drugs don’t show up in the insurance company claims data;

An insurance company writes to alert a doctor that a patient on expensive medications may be noncompliant with his regimen because he has only used 60 days’ worth of medicine in the last 90 days. That’s because the kind doctor slipped the patient enough samples to save him a copayment once or twice;

A prior authorization unit demands a “peer-to-peer” telephone call before they will authorize an imaging study. All the information required may be in the medical record, but they still want a call. The practicing physician is kept on hold for ten minutes ($70 opportunity cost) only to read out loud from the record to the insurance doctor. Other times the rural doctor has to tell a big city cardiologist that he ordered a nuclear stress test on a female patient instead of a stress echo because the nearest facility that does stress echoes is 200 miles south on icy and snow-covered roads in the middle of January.

The economics of the medical practice require a certain productivity level just for survival, so the administrative duties are often given inadequate time, or no time at all, resulting in shorter patient visits just to capture a few moments to do the administrative work. There is still considerable unreimbursed provider overtime, leading to physician stress, disillusionment and burnout.

We should be paid for this work, as well as for reviewing results and maintaining our patients’ medical records over time and in between visits – all noble ambitions of the medical home.

We should also, of course, be paid for face-to-face visits with our patients.

But who should pay?

The problem with having private insurance companies, Medicare or Medicaid pay is that patients have little reason to consider value for money spent. It’s natural to be less concerned about how we spend someone else’s money, particularly if that money used to be ours, before the tax man or insurance company took it away from us!

I know I am only a country doctor, but I have seen many different systems of health care since I started medical school in 1974, so in my next installment I will outline A Country Doctor’s Proposal for Health Insurance Reform.

How Should Doctors Get Paid? – Part 3

Should we be paid for outcomes?

This is often proposed, but I have trouble understanding it. Real outcomes are not blood pressure or blood sugar numbers; they are deaths, strokes, heart attacks, amputations, hospital-acquired infections and the like. In today’s medicine-as-manufacturing paradigm, such events are seen as preventable and punishable.

Ironically, the U.S. insurance industry has no trouble recognizing “Acts of God” or “force majeure” as events beyond human control in spheres other than healthcare.

There is too little discussion about patients’ free choice or responsibility. Both in medical malpractice cases and in the healthcare debate, it appears that it is the doctor’s fault if the patient doesn’t get well.

If my diabetic patient doesn’t follow my advice, I must not have tried hard enough, the logic goes, so I should be penalized with a smaller paycheck.

The dark side of such a system is that doctors might cull such patients from their practices in self defense and not accept new ones. I read about some practices not accepting new patients taking more than three medications. In the example I read, the explanation was not having time for complicated patients, but such a policy would also reduce the number of patients exposing the doctor to the risk of bad outcomes.

A few comparisons illustrate the dilemma of paying for outcomes:

Do firefighters not get paid if the house they’re dousing to the best of their ability still burns down?

Does the detective investigating a homicide not get a paycheck if the crime remains unsolved?

Does the military get less money if we lose a war?

Even if we were to accept and embrace outcomes-based reimbursement in health care, how would we measure outcomes?

We already know that an episode of care, say a hospitalization for heart failure or a COPD exacerbation can seem successful, but the 30-day readmission rate can cast doubt on that. First, of course, not all of that “outcome” is dependent on a single provider or even a group of providers, but involves ancillary staff, hospital resources and much more. This is one of the thoughts behind the Accountable Care Organization movement. Second, much of what happens in sickness and in health is not provider dependent at all. An unusually miserable weather pattern can make COPD relapse rates higher one month than the next, for example. What kind of bureaucracy would it take to create a payment scheme that factored in such things? And would our health care dollars really be better spent on such accounting efforts than on nursing staff levels or something else?

Other than short term outcomes for gallbladder surgeries, pneumonia hospitalizations and such discrete episodes of care, how would we measure “outcomes”, for example in primary care and disease prevention?

For pediatricians, would we follow their patients’ health into old age to determine how good their early care was? How about when patients switch doctors, often because of insurance coverage changes – who gets the credit or blame for future bad outcomes?

In short, I think outcomes-based reimbursement works only in a limited sector of healthcare. For primary care, and specialty care that spans over any length of time, we need to get back to basics in the form of Honest Pay for Honest Work.

And that will be the topic of my next installment…

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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