What does a modern medicine intern do all day?

What does a modern internal medicine intern do all day (and night)?  It turns out they spend 40% of their time at work using a computer, another 20% on other aspects of patient care that is not in the presence of the patient, 15% in educational activities, 5% on basic needs like walking around and eating, and only 12% in direct patient care. Direct patient care includes interviewing patients, examining patients, doing procedures for patients, talking to family members, and all activities that are in the direct presence of the patient or their family.

This information is reviewed in the recent NEJM Journal Watch which discusses an Annals of Internal Medicine article about a 2012 observational project that used trained observers to look at what interns actually do with their time. They spend 60% of their time in “indirect patient care” which includes discussion of cases with other providers and making chart notes.  Unfortunately most of this time sounds like it is largely documentation of the 12% of the time they actually take care of patients.  Two-thirds of the indirect patient care time, or 40% of their total work time, was spent on computers, mostly in computer generated documentation of care.

What does a modern medicine intern do all day?

Graph depicting how internal medicine interns spent their time in  2012

Use of computers is intended to improve patient care.  In many ways it may improve patient care by making information more easily available, allowing for care reminders, protocols, etc. to assist in care.

Arguing against this is the fact that a similar study noted in this NEJM article showed that in 1989 interns spent 20% of their work day in direct patient care.  Keep in mind that their work day was much longer in those days before mandatory limitations on house staff work hours, so the absolute time spent on direct patient care was probably even greater than this percentage difference suggests.  This reduction in relative and actual time in direct patient care does not portend well for training of young physicians.  If interns spend nearly 40% less of their time interviewing, counseling, examining and doing thing to/with patients than physicians did 20+ years earlier it seems unlikely that they will develop better patient care skills.

This is not incongruent with my observations of how medical care is going in general.  We are spending more and more time in the arena of “indirect patient care.”   This is a euphemism for making chart notes, completing tasks required by various outside parties. Insurance companies want documentation for physicians get reimbursed, they also demand information and documentation to get prior authorizations for everything from medications and testing to surgery.  Others who need physicians to provide documentation include employers, nursing homes, schools, hospitals, coaches, parents, children, department of transportation officials, pharmacies, and attorneys among others. It seems like I spend many hours daily on tasks that provide little or no direct health benefits to my patients.  This study suggests to me that we are indoctrinating young physicians into this mindset early. 

The article ends with, “However, things clearly are moving in the wrong direction. These fascinating data ring completely true and should give program directors impetus to reevaluate critically the present routines of clinical training.”

I could not agree more.  The issue though is not just in how physicians are trained. It is in what the system we work within demands from physicians in terms of documentation.

Edward Pullen is a family physician who blogs at DrPullen.com.

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  • azmd

    If we are training them to do what they will being doing when they finish training (which seems like it should be the point of training), then it’s hard to know what exactly is wrong with these numbers.

    I probably spend about 20% of my day in direct patient contact and the rest on the computer or interacting with reviewers, or completing other clerical and administrative tasks related to regulation, billing and coordination of care. Many of these tasks are assigned to me because the hospital doesn’t want to pay a clerk or an administrative person to do them.

    When we say “things are moving in the wrong direction,” I think we should be careful to specify that we are talking about the practice of medicine in general. Instead of spending even more time on bureaucratic efforts to increase the time that trainees spend interacting with patients, maybe we should be spending that time on advocacy efforts to save our profession and attend to our patients’ complaints that none of us have enough time to spend with them.

    • edpullenmd

      You are absolutely right, in that the part of the system that is broken is that we spend our time on the non-direct patient care aspects of our jobs in order to get paid, not get sued, and meet other regulatory and clerical demands. If we could get the rules changed we could focus on taking care of patients rather than taking care of the patient’s medical record. Thanks for the clarification. Unfortunately we are teaching our physicians in training how to do just what we do.

      • azmd

        Which is why, when they complain, I think we should not fall all over our collective selves to respond “Oh, you poor things, you’re right, let’s organize a subcommittee to create an initiative to drive change in the intern-patient interface,” or some such mumbo-jumbo, although I recognize that this is just the type of activity that certain academic physicians love to immerse themselves in.

        What we should be saying to them, really, is “Welcome to the brave new world of medicine. If you don’t like it, you should make sure that you are a dues-paying member of any medical organization that appears to be making efforts to advocate for the survival of our profession. And speaking out on the Internet probably wouldn’t hurt, either.”

    • Ala Awad

      well said, the problem lies in that there’s no one to do the clerical work and thus why most of the time isn’t spent on direct patient care, so it’s not that young doctors aren’t sufficiently educated or trained, it’s the system problem that needs to be corrected.

  • Shirie Leng, MD

    All the data that is required has to be entered by someone. Interns quickly learn that they are just typists. Spending time with patients isn’t as visible or “productive” as generating great data. If we need secretaries, let’s hire secretaries.

    • Dr. Drake Ramoray

      But secretaries with enough a medical knowledge to not be dangerous cost more than interns on an hourly basis. My residency program tried this after the work hour change and it failed miserably. The secretaries can quit pretty easily

      • https://www.facebook.com/arobert6 Alice Robertson

        How long did handwritten notes take and without an electronic search ability? When my son went to college the private college in NY wanted his shot records with our local doctor who we were friends with. I still never got them. They were in storage on film and the doctor said all records more than two years old go there and no way was his staff willing or able to do that.

        • Dr. Drake Ramoray

          Handwritten templated notes (the exam can be circled from a list) probably takes a third of the time. The problem for me is that I refuse to stare and click at a computer screen while I see patients as most find it much more disruptive than me taking notes. As a result I’m left doing my note after the visit (not to mention electronic templates work well for an evaluation of a cough but not so much for thyroid cancer). Many a doctor on this blog has said I’ve made too much work for myself. This is probably true, but looking at the requirements for stage 2 meaningful use I will be one of the docs that conducts a patient interview while clicking at a computer and staring at a screen soon enough.

          I actually have thought the best way was a hybrid of EMR and transcription services. I can have a clickable exam template, dictate the history and the assessment and plan which is then legible for all to see (we do have a few local docs still pure paper and I can’t always read the notes which is the major drawback of handwritten notes), and is relatively efficient. The problem is that this is prohibitively expensive because now you are paying for an EMR and transcription services.

          When you boil it all down EMR probably could be useful. The meaningful use standards however blow any sense of efficiency out of the water. This just adds insult to injury that the modern internal medicine doctor is quickly becoming a glorified medical transcriptionist/floor secretary who also happens to be responsible for patient care. This article regarding how time is spent just adds concrete data to what doctors have been saying for about a decade.

          As for immunization records you were seeking, each state has provisions for how long medical records must be kept and be available for outside facilities and patients. In my state, if I remember correctly it is ten years.

  • Ron Smith

    I suspect that if you had some reversals in those percentages, you actually might have poorer patient care. I prefer to think that the quality of care goes up within that 12% of time spent with direct patient care, with some consideration.

    Just this morning I was considering that all the effort that we are required to do is OK, but probably not necessary. What I would suggest is that for certain things like ear infections, pharyngitis, etc, would be adequately documented at a diminished level. Unfortunately the problem is that the third party payors have equated that with poorer quality of care or not getting their money’s worth.

    That is just not so.

    If we could lessen the documentation required for certain things that don’t need extensive documentation, then we might be working more towards increasing the ‘supply’ of provider care. As it is, I document almost as much for sick visits as well, except for growth and development, and such.

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • guest

      but that would be letting the doctors decide on the best treatment plan…

  • penguin50

    Could you clarify whether it is considered “direct patient contact” when a doctor is technically with a patient (inpatient OR outpatient) but spends about 80 percent of that time facing away from the patient and entering information into the computer (perhaps murmuring something now and then), or is the 12 percent figure covering only speech-with-eye-contact and hands-on care with a patient? No snark intended! I’m just unsure what this term covers in practice. You seem to be making a distinction between data entry and “direct patient contact,” but the two seem rather mixed in practice.

    (Side note: Devoting only 5 percent of one’s time to walking around and eating seems WAY too low. One hour out of twenty for eating and moving from place to place in a job that requires one to constantly be moving about? Makes my heart sink. Residents are run ragged. The least we can do is let them eat.)

    • edpullenmd

      I have no idea exactly how generous the observers were in defining “direct patient care” It may be data entry in the presence of the patient counts.

      • azmd

        Since for billing purposes, nothing that we do is considered billable unless done in the presence of the patient, one has got to assume that data entry in the presence of the patient is considered to count as “patient contact.”

        It would be interesting to see what would happen if patients would organize to complain to third party payers about the fact that reimbursement is structured so that administrative activity on behalf of the patient is only reimbursed if you do it in front of the patient.

        As it is, by not making patients more aware of this requirement, it makes us look like the bad guys for using the patient’s time with us to complete administrative tasks rather than talk to the patient.

        • guest

          great point. It is ironic how the EMR’s to “help” with making pt care easier actually robs the necessary one on one time with the pt. The EMR requirements actually work against the rules that require time spent with pts to get reimbursed. what an oxymoron. again great way of explaining the irony of it all.

          • https://www.facebook.com/arobert6 Alice Robertson

            I wonder if AZMD is working in a system like the VA? Because what she describes seems more government, bureaucratic based? But then again I am at Cleveland Clinic where they are considered ground breaking as far as IT. Patients around here love EMR’s (and don’t really care if they will lose privacy which is an odd thought to me) and the ability to read their records and test charts (even images can be seen online or Dr. Connect so you can go out of the system. I don’t know one single patient in this area who doesn’t feel empowered by them). Patients around here complain if a doctor can’t type or doesn’t seem tech savy (and the younger ones seem to use their smart phones and computers with the ease of eating a sandwich). I am not sure patients are high on sympathy for doctors having to spend time on billing, etc. when they feel they gained so much. But I am just one patient who likes to talk to people in the cafeteria:)

            My friend’s husband runs the IT section of the Northeast Ohio VA section and they are very proud of the data crunching ability and have improved care vastly. The VA patients around here seem relieved too. They feel the quality has went way up, and some of the vets I know (my friend and her husband have private insurance, so while he isn’t ready to go to VA care they use it for post-traumatic stress and a few other things the VA seems exceptional at dealing with).

            I don’t know….where I get care very little time is spent at the computer now and because they are going to let patients see doctor notes the doctors ain’t saying as much:) I would say 90% of a doctor visit is with the doctor speaking directly to the patient and I see a lot of doctors, take my parents and kids so we have far too much experience using the system. Maybe they are taping it and filling in the blanks later because I can’t figure out how our one doctor can quote verbatim even if I stay away for three months at a time. No doctor or human who sees the vast amount of patients he does could remember me almost word-for-word. Good grief I a surprised he remembers me far less what I said. Next time I see him I am going to ask him if he has is running the tape recorder on his cell phone then filling in data after patients leave. He will laugh at my dramatics but gosh I wanna know how he does…maybe he’s a robot….he’s absolutely astounding as a doctor.

          • azmd

            I think it varies quite a bit from EMR system to EMR system. Ours is not as well-known for being user-friendly as the system that the VA for example uses. Don’t know what the Cleveland Clinic is running.

          • macbook

            So you are saying administrative work, like documenting in the EMR is billed differently if done in front of a patient vs after they have left? I didn’t realize this? How do doctors bill for this?

        • penguin50

          I’m terminally ill, so I’m going to give myself a pass on trying to “organize” other patients to take action, but I can certainly write a letter myself. Thank you for this very constructive suggestion.

          • azmd

            Thank you. I am very sorry to hear of your illness.

  • buzzkillerjsmith

    Vendors are key. Olson’s Logic of Collective Action explained this phenomenon back in the early ’60s. Focused groups get it over on unorganized groups almost all the time.

    I’m not sure EHRs were originally developed to mine data to control us. I think the vendors were important, as were the silly, silly doctors who thought that this stuff would greatly improve and cut the cost of medical care.

    Perhaps the third party payers and the government came on a bit later. I think the government’s interest in data mining for control purposes has really ramped up with Obama. I don’t think this stuff was on Bush’s radar. I agree that the feds and others are now salivating at the prospect of complete control.

  • buzzkillerjsmith

    Good post, Dr. P. It’s important to assign numbers to these matters. If the the percentage of time has gone from 20% to 12% and if interns now work fewer hours, it could easily be that direct pt care has been cut by more than half.

    Perhaps jockeying computers is what other people would see us doing for a living, maybe with a little history and physical and lab ordering on the side. We all know admindocs, for whom meetings and memos are the whole point. Maybe the new generation of primary care docs will be mainly admindocs.

  • Dave

    I’ve long thought that this is a big reason that students are avoiding primary care. Even medical students have a paltry amount of actual patient care time relative to time spent in front of a computer screen or participating in yet another mandatory activity. The other numbers shift around a bit, but the 12% patient time is probably the same. People who would be drawn to primary care are usually the very people who long for patient interaction, for meaningful time spent with real human beings. Is it any wonder that many of these people discover they can achieve this goal better in a subspecialty field?

  • https://www.facebook.com/arobert6 Alice Robertson

    So the link gods are letting links through now are they?:) You know my friend in IT came by tonight and said at the big conference at Cleveland Clinic today the whole emphasis was on data (using epatient Dave and the Give Me My Damn Data websites as instigators to what patients want). They are releasing doctor’s notes now via EMR’s and patients are loving it. But your caution is appreciated because HHR has already requested the data. We are naive to think that this data will remain as private as it once did. In the UK the government owns the patient’s data and it’s a nightmare to get ahold of it. We even went to a lawyer who said for $400 she would try but don’t count on it. Now that may be true with paper or computer data, but the point is the government controlling our data is problematic.

    Basically they discussed bundling, volume, etc. and said with Obamacare the emphasis will be completely on IT saving them money. So it’s a trade-off with patients getting the information doctors either withheld or took to long to share, but they are going to lose privacy.

    • Dr. Drake Ramoray

      There certainly is a case to be made for patients to have easier access to their medical records, however:

      1.). I’m not aware of any data that it improves patient care, efficiency, or safety. Some discussions that have resulted from patients having access to my notes included comments on contextual inaccuracies from voice recognition software (butt pressure instead of blood pressure. At least we shared a laugh) and an 85 year old patient who was very very upset that I had her pregnancy history incorrect and that she had had 4 pregnancies not 3 pregnancies.

      2. It probably has some effect on patient satisfaction.

      A paper from JAMA 2003 wasn’t initially very promising showing only moderate benefit

      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC150366/

      In 2102 JAMA is no longer focusing on quality but showing how portals can decrease utilization of services (something only useful to physicians if we accept the concept of bundled payment) as any time and effort expended on phone calls, portals, e-mails etc. is not reimbursable. So for portals to be useful I have to accept the concept of the PCMH, ACO, or work for a hospital.

      http://jama.jamanetwork.com/article.aspx?articleid=1392562

      3. Lastly every doc I know in my somewhat rural area is fairly convinced we will not meet the percentage use goals of our portals that are established by the government for meaningful use. This apparently is also a problem that for the Mayo Clinic

      http://www.kevinmd.com/blog/2013/04/build-patient-portal.html

      I have a few patients who wish to have a copy of their labs and notes and I am happy to provide them at the visit or as soon as they are available. It’s just more meddling by third party payers.

      • https://www.facebook.com/arobert6 Alice Robertson

        I find data crunching both terrifying and useful realizing it’s the tsunami for patients who don’t see a greater good by their use. It’s everywhere with banks, credit cards, grocery stores (great chart at the Economist on this).

        Drake…I just gotta say you seem like a really good doctor. If I lived near you I would beg for your name and bring my daughter to you for treatment. But since that’s not going to happen I will enjoy and learn from your posts because you are part of a very small set of doctors here who will discuss with more than just your peers. And when that other subset of doctors outspeaks patients they don’t realize the opportunities they are missing. Thank you!

      • guest

        It’s interesting that the general public has this idea that EMR’s( computers) mean progress and believe all the nonsense that is spun to them about how efficient and helpful it is. Meanwhile they can see their care actually suffers.
        It’s frustrating that it takes a study to prove something that is self evident. And even all these studies don’t seem to be put to any good use to change things. Most frustrating. There seems to be no one listening. I blame the federal government more and more for fostering these bozos and not listening to doctors.
        It is enraging and absurd that physicians were not involved in designing it. It is absurd that docs on this site have to design their own to have meaningful medical records they can use. ( I use that word ‘meaning” in its true definition).
        I am saddened to hear every doc involved with EMR. It’s dehumanizing for both pts and physicians and no study is required IMHO. ( Although I was glad you posted the study. Only educated people especially physicians care about studies. Business EMR companies don’t care about studies and if anything are threatened by information that exposes that they do not really offer anything of value to society.

      • macbook

        I’m a medical resident and finding this website to be so educational. We don’t learn about all of these business aspects of medicine in residency…!

        I definitely agree that the EMR does not lead to better patient care necessarily and that it really slows us down. We spend enormous amounts of time “documenting” and to write a proper note that goes into full detail of the patient encounter that is worded properly in all the right ways, takes a lot of time! The one aspect of EMR that I think is very useful though is having all the data readily accessible in one system – no need to decipher handwriting, everything is clearly written in one consolidated form. Sometimes trying to go through a paper chart to figure out what is actually going on with a patient can be quite tough whereas its much easier electronically.

        Based on the comments to this article, private practice docs seem pretty unsatisfied with the EMR. Can you guys just go back to papercharts then? Pardon my naivety, but if its slowing you down, costing more, getting in the way of patient interactions etc etc it seems to make sense to resist it….

        Also, one thing I was thinking is that it is pretty unfair that the only thing that is reimbursed in medicine is direct patient encounters. What about all the time that is spent on the phone, all the time spent writing letters to patients, how can all of that go unpaid for…?!

        • Dr. Drake Ramoray

          EMRs are more useful in a large medical center especially if the patients receive all of their care there. This is in part because you have all the data in one place, and in part because they have house staff to do the busy work. In a small independent practice they are far more trouble than they are worth because a single page flow sheet in the front of the chart will tell you most of what you want to know, is easy to maintain, and doesnt cost my practice $1800 a month in vendor fees not to mention all of the computers we had to buy.

          Any outside records have to be scanned in, which has actually increased our staffing needs for medical records. The EMR has done nothing to increase the numbers of patients we can see. So our overhead went up and our revenue is essentially unchanged.

          In the short term we could go back to taking paper charts however there are increasing penalties from Medicare for not using an EMR and meeting the meaningful use requirements established by the govennment. One way to do so would be to stop seeing Medicare. It’s not occurring in my state but private insurers could readily have the same requirements if they wish. No longer seeing Medicare not only has financial ramifications but political ones as well as we are the only specialty of our type in the area. For starters if we stopped seeing Medicare the local hospitals would probably bring in their own Endocrinologists.

          As for not getting reimbursement for phone calls, prior authorizations etc. welcome to Medicine. Only Anesthesia, Radiology, and to some extent Derm get out of this. Oh and ER.

          Good luck resisting. There is an article on this website about not obstructing these changes and Obamacare written by one of the big wigs from the ACP. Medicine in this country is quickly no longer about a single doctor and a single patient, but about community outcomes, and per capita spending. The AAFP and the AMA are equally useless if not actually working against your interests.

          If you dont want to go into academics, specialize or go concierge is my advice. I would still choose Endocrine, although I thought long and hard about Neurology, and GI seems to be the happiest bunch in my area. Cardiology is a slave to corporate hospitals at this point and I couldn’t fathom doing Oncology in a bundled payment system. Plus there is the whole dying thing. Not something I wanted to deal with on a regular basis.

          So far the saving grace for Endocrine is that there are very few of us, and to a lot of docs what we do is one big black box. (I suppose Rheumatology shares that honor as well but I had no interest). At the end for the day do what you love, even something else if it isn’t medicine, because things always change. Cardiology was where it was at for medicine specialities when I was in training and that all changed within a couple of years of my finishing my Endocrine fellowship.

          • macbook

            Thank you for such a helpful reply!

            Can you explain why cardiologists aren’t doing so well? How has that changed recently?

            If you were to not take medicaid, the local hospitalist would get another endocrinologist to cover their inpatients and make sure the inpatients can have local outpatient follow up…is that why?

            Also, have you ever contemplated doing a direct payer model where patients pay a certain flat fee when they come to see you for appointments?

          • Dr. Drake Ramoray

            Cardiologists almost universally now work for hospitals because Medicare has reduced reimbursement rates for imaging and procedures so much that it is not financially viable to remain independent. The reimbursement for services continues to go down all the while hospitals are able to charge exorbitant facility fees for the same service and make a large profit, often times at the same practice with just a different sign on the front. A facility fee is essentially an outlandish overhead fee that hospitals charge third party payers because of some claim to increased overhead. An U/S in my office costs about $200 and the local hospital down the road collected $554 for the same study.

            As for hospitals it’s Medicare we need to continue to see not Medicaid for the political ramifications. It is generally well accepted in our community that specialists don’t see Medicaid (in our case unless phone request by the physician).

            We have considered a direct payer model, although that isn’t really feasible unless we start doing primary care as well. That is actually a disadvantage of being a specialist, although I do have a few cash pay patients who choose not to have insurance (mostly young people with simple thyroid cases).

            For now my group is looking to contract with a private clinical research firm because we think we will need an alternative revenue stream to remain independent. One of the things I have mentioned on another thread is that come January 1st. Medicare is reducing the reimbursement of ultrasound guided thyroid biopsies by 50%. We offer the service already at the fraction of the cost of hospitals because they charge facility fees as I described above. We have to decide if we we will continue to do them in the office or send them to the hospital. We also have to decide if it is worth it to replace our ultrasound machine soon.

            In the short term it’s not a pretty picture for independent private medicine.

          • macbook

            So if you work for a hospital and not private practice, are you placed on a flat salary? I guess i’m not clear why it is different for cardiologists – lets say you are a general cardiologists not doing any procedures. Why can’t just seeing patients in the office, just like any other specialty, and cover your overhead so that you can stay in private practice? Are the reimbursements for seeing patients (no procedures or imaging) so low that you can’t cover overhead?

            For the direct payer model, why wouldn’t that work so much with specialists. In theory, it should be similar to primary care? You would just charge a flat fee every time you saw a patient instead of having to battle with the insurance companies.

            I also wonder though for primary care specialists going w the direct pay model, their patients will still have to have some basic insurance though. How are they going to cover imaging and labs without any form of insurance.

          • Dr. Drake Ramoray

            Some hopsitals are salary models although unless your an academic center that is usually a money loser for administration because you have no incentive to see more patients. Most hospitals work on some form of RVU (Relative Value Units) established by the feds. I know one hospital that for awhile you clocked in like everyone else and got paid hourly, but a few bad apples worked the system and would clock in all day and see only 3-4 patients. Don’t fool yourself, when you are an employee of a hospital they will be making money off of your work. (Not true in all academic centers as some departments are known money losers on their own (the ER and IM clinics being the usual offenders).

            Cardiologists (nobody for that matter) can pay the bills and make a living on just E&M for office visits. That’s why docs move labs in house, do botox, or find other ways to make money. This is also one of the reasons why nobody goes into primary care. Big hospital centers avoid this issue with their facility fees.

            You can do a direct pay Endocrine practice (I’m aware of a handful), but they all do primary care as well (100% even the guys presenting at meetings about the idea.) It will not work in our area because 1.) The community is probably not big enough 2.) The providers I work with enjoy working with each other. 3.) We are all equal standing and share the same non-compete area and financial penalty (We call it our suicide pact) 4.) None of us want to do primary care (even our PA). I could probably do it, and if I was ten years younger and closer to my primary care training I might. Given my family and obligations outside of myself it’s not really feasible for me at this time. I’m a little old to change my model (take the financial risk and uproot my family) and too young to retire.

          • macbook

            Wow I just read the article you attached. Very enlightening! I can’t believe they are doing this and getting away with it. It sounds so wrong and I feel like this is the push from all the big lobbying organizations, otherwise it makes no sense as this is a huge cost to the system. They complain that cost is too high in the system, well if that is truly the problem, it seems like there are very clear ways to cut them. But as doctors we are the weakest on the totem pole, have no pull or advocacy so they go after us…

            Based on what I have been reading, it seems like as doctors we are trapped. IF we go into primary care, there is little hope of making ends meeting. If we specialize, we will be a hospital employee without control of our own business and probably working like crazy to meet the hospitals RVUs. All the while they keep cutting reimbursements to doctors saying that the cost of healthcare is too high when we see that really the bulk of cost does not come from doctors salary..?! What is even worse, it seems that if things continue this way and all practices are bought out my hospitals then eventually they will have a monopoly on us and therefore be able to pay us whatever it is that they choose….

          • macbook

            Also, if you go into a direct pay system, why can’t you have multiple partners in one office. If seems to make good sense, that way you have more revenue for a given overhead and would probably make it easier if someone were to go on vacation? Most direct payer practices I have seen were just one doctor though.

          • https://www.facebook.com/arobert6 Alice Robertson

            Why aren’t you teaching at somewhere like Case Western? Your posts are helpful!

  • https://www.facebook.com/arobert6 Alice Robertson

    Just walk into Cleveland Clinic this week and every patients gets brochure that you are going to pay those fees because without them they can’t stay in business….translation….be thankful for the fees because they get you good care. But just like Obamacare offering the bureaucrats fabulous care there are exemptions not mentioned in the pamphlet. It irritates me because last fall one of the fees was $251 for one visit because it was a new facility…and the Clinic announced they are cutting about a third of their work force.

  • http://symmed.ru/ rada

    Indeed computer and documents collected during working hours.