A Country Doctor Writes:

A surgeon evaluates patients and performs surgery. But surgeons don’t administer the anesthesia. They also don’t sterilize their instruments or fetch them during the operation nor do they hold the retractors while also cutting or suturing. They also don’t do all the dressing changes and repositioning of patients postoperatively. They move on to other surgeries.

A whole team is working alongside with the surgeon to help the operation go smoothly without wasting the surgeon’s (or patient’s) valuable time.

Contrast that with primary care.

Some of the other people on our team, like our medical assistants, used to prioritize incoming results, reports and messages to help us get to the most important ones first.

Those days are gone.

Modern EMRs are designed to have the provider be the one who receives everything and then delegates to the medical assistants to tell the patient or have the test repeated or whatever needs to be done.

Then we have new categories working with us – pre-visit planners is one of many names for them. Their job is to look for “care gaps” and then tell the providers they need to order mammograms, colonoscopies or whatever.

(Years ago, pre-visit planning used to have the purpose of making sure we had what we needed to carry out the visit: a visit like “Followup MRI” would mean checking if the patient has had the test and if we have the result, but that’s not what today’s pre-visit planners do.)

Neither of those job functions are meant to help the primary care provider do what only people with a license to practice medicine can do.

The surgeon’s expertise is leveraged but the primary care provider’s isn’t. We are doing more and more non-doctor work, in large part thanks to our EMRs.

This explains both the doctor shortage and the burnout epidemic. And it is a perpetual motion machine: more non-clinical duties means more of us quit, which makes those who remain even more likely to burn out and quit.

The solution is obviously simple:

Hire people to sort and prioritize incoming information so the provider doesn’t waste time on routine information when their attention should go to the most important information first.

(And for any non-medical readers out there, computer generated flagging of an abnormal chemistry profile is not helpful. There is a statistical expectation that 5% of lab results will be abnormal even in normal people and therefore a panel with 20 items would be expected to have at least one abnormal result, and thereby be flagged as a priority item in the physician’s electronic inbox. A modest amount of knowledge is required for this job.)

Give the pre-visit planners authority to check with the patients by phone or electronically if they want a mammogram or colonoscopy or whatever instead of ordering the provider to do that in their next visit, which is likely to also have a lot of other requirements, like depression screening, medication reconciliation, repeating any elevated blood pressures, checking desired gender identity and whatnot.

We aren’t trying to put ourselves above our team members when we resent doing what non-physicians could do. Our visits and the billing codes they generate pay all our wages and keep our clinic doors open. Why aren’t our skills and knowledge leveraged to their fullest extent these days? They used to be…

I’ve been posting my thoughts and experiences on A Country Doctor Writes for over 15 years now and here are a few statistics:

The blog has had 687,308 views as of this writing and 366,807 unique visitors. I have published 962 posts, and the one with most views was in January of this year, with 13,730 views:

The last one on this year’s list of posts with only 2 views is from 2014, when it had 156 views, and it is actually one of my favorites:

My best year ever was 2021, when I had 5 posts with over 8,000 views. They were about weight loss myths, doxepin, nonfasting labwork (a video), Primary Care and Walgreens pushing for 90 day scripts.

I have a red bump on my nose that started out looking like it was going to be a little skin cancer, but which now looks just like a hemangioma, a little blood vessel-filled lesion of mostly cosmetic significance.

Sitting in front of my laptop tonight I felt and saw blood dripping from my nose. I sometimes get nosebleeds, so I just pinched my nose and went in the bathroom. Looking in the mirror I saw this was no ordinary nose bleed, it was my little hemangioma that had sprung a leak.

I still reached for a cotton ball and saturated it with decongestant nasal spray, which is what I do to stop nose bleeds, and I just placed it outside my nose. Holding it there with some pressure, the bleeding slowed down after which I applied a styptic pen to cauterize it. I keep that around for the very rare shaving accident a man can have.

Simple tools to have around. Back to the computer…

Oh, that reminds me of when I diagnosed my own vitreous detachment of my eye while visiting family in Sweden.

I love medicine. I love being a doctor. I thrive on making diagnoses and treating disease. I find deep satisfaction in educating and empowering patients.

But, as I have said many times, I am a problem solver and not a bookkeeper.

Doctors today are required to do more and more EMR data entry in more and more stilted ways with less and less team support. All the while we are under pressure to be both productive in terms of patient volume and comprehensive in terms of both disease management and an ever increasing burden of public health that really shouldn’t require a medical degree at all.

We have become bottlenecks in the flow of information. Our electronic inboxes exist so that our EMRs can document exactly when we saw a test result and what we did about it. This creates a tight bookkeeping workflow but ignores the fact that we can’t be in two places at the same time: We are scheduled to see patients all day long, so our inboxes fill up with unsorted data, unseen by the nurses and medical assistants, who used to help prioritize incoming data before the EMRs changed all that.

I have finally made the decision to move away from working in this unsafe, unsustainable and wholly unsatisfying way. I am transitioning away from traditional fee-for-service Family Medicine.

I will be the lead physician in the entire state of Maine for a new kind of practice that eliminates the hamster wheel of counting face-to-face encounters. I will personally and through supervision be responsible for the care of a fairly small number of complex, high risk Medicare, and later Medicaid, patients. My organization will be paid per member per month. This will avoid unnecessary visits, and it will make it practical to use remote monitoring, phone calls, video visits, and any other means of communication to stay in touch with my patients.

The foundation is house calls. I loved doing house calls when I worked full-time in Bucksport many years ago. These days house calls are viewed as not very profitable because by the time you drive to somebody’s house and see them and then drive back to the office, you could have seen two or three people in the office. But with the capitated payment model, a house call will teach you a lot about how the patient lives, and what their circumstances are, and that will help you make better decisions for their future care.

I will document my process of getting to this decision and my progress in entering this new type of practice on my Substack in a post category titled PROGRESS NOTES. This is a learning experience for me and a growing experience. My patients will be those in managed Medicare, also called “Medicare Advantage”. I already have many patients with that type of insurance, and many of them are very complex. It has been difficult to give them everything they need because in the traditional type of clinic I work in, we don’t get paid more when we spend more time with the patient. Any visit is paid the same, so there is no financial reward for being comprehensive, except some minor bonuses for the practice when quality standards are met.

I have been skeptical of managed Medicare, in part because they are stingy with authorizing and paying for CT scans when I think my patient has cancer, but in terms of outcomes for chronic diseases, the statistics are clear, because of the extra support managed Medicare provides, patients with that type of insurance have better outcomes. One insurer, WellCare, even sends people healthy food through a program called Mom’s Meals.

In “PROGRESS NOTES“ I will document what I am learning and what I experience in this new phase of my clinical career. Please join me.

https://acdw.substack.com/

In spite of all the talk these days about health care teams and in spite of more and more physicians working for bigger and bigger healthcare organizations, we are becoming more and more isolated from our colleagues and our support staffs.

Computer work, which is taking more and more time as EMRs get more and more complex, is a lonely activity. We are not just encouraged but pretty much forced to communicate with our nurses and medical assistants through computer messaging. This may provide more evidence of who said or did what at what point in time, but it is both inefficient and dehumanizing.

Why do people who work right next to each other have to communicate electronically? Why can’t my nurse simply ask me a question and then document “Patient asked whether to take aspirin or Tylenol and I told her that Dr. Duvefelt advised up to 2,500 mg acetaminophen/24 hours”. It would be a lot less work for me, even if I have to sign off on the darn thing.

And just because it now takes us longer to do our work, there is less slack our day. This makes for less curbside consults, less sharing of clinical experiences between clinicians, less social contact with other staff categories.

All this leads to professional and social isolation.

And, you know me, this reminds me of a James Taylor song, Millworker:

Then it’s me and my machine
For the rest of the morning
For the rest of the afternoon
And the rest of my life