I complain about my job all the time. The frustrations are endless. For example, EMR changes that seem pointless and create more clicks, instead of fewer, the constant barrage of patient emails in my inbox that start with “I have a question about X result” because results are released immediately to patients before I have seen them, patients that arrive late without having filled out medical history form ahead of time, patients that get up and leave because they perceive too long a wait time … And this only scratches the surface of what I hate about my job.
I am a gynecologist, and I have been in the same practice for 22 years. This means that I have a lot of long-term patients. Many of these patients get funneled to the nurse practitioner for their annual exams, especially if they have no complaints. The NP often triages those who have problems, then sent to me for management. This system seems like a good way to manage things, and I do have to remind myself of this frequently. But when I get a patient with 20 days of heavy bleeding, who clearly has anovulatory bleeding by history alone, she needs more than a tranexamic acid band-aid. She also doesn’t need a 10-day delay in seeing me to get a formal ultrasound when the NP’s informal office ultrasound shows a 25 mm endometrial lining. For you non-gynecologists, this is very thick, and she needs progestin management ASAP. (She also ought to be sent for a CBC and hCG, and started on iron, but I digress.)
Now don’t get me wrong, our NP is extremely popular with our patients. They love her. She’s very social and always writes a very detailed updated social history. She also writes the chief complaint in the social history, while the actual HPI template often says “no complaints” about the issue. She also takes a very detailed family history, complete with each grandparent, aunt, uncle, and cousin who died of natural causes. So, when I read her note, I have to wade through all kinds of crap to find out the information I need to manage her. I recently reviewed the note of a new patient referred to me with irregular bleeding. Her intake form noted a uterine anomaly, and the NP did not put this in the GYN history or medical history. The only mention was in the surgical history with a brief note about her vaginal repair at delivery. (There was no note of any OB history or renal imaging.)
Now, some of you reading this may think I am asking too much of an advanced practice practitioner. I don’t think so. While she may not know that this patient needs to have renal anatomy confirmed, she should know to put “uterine anomaly” in the proper place in the medical record. Or, if she had any level of curiosity, she would have looked into care everywhere, where I had to go to put the pieces together that confused me. Advanced practice practitioners can be a useful part of the medical team, but if they make more work, instead of less, for the doctor, that is a problem. And once a patient is referred to me, she is no longer a new patient, so I get no additional time to see her. Of course, it takes me just as much time, if not more, to see this established patient, fix the medical record, and come up with appropriate tests and management.
So back to why I loved my job yesterday. The first patient was scheduled for a telehealth visit. My medical assistant couldn’t connect the video, so we did it by phone. Minorly frustrating. The good thing, I was able to get her in later in the afternoon with the proper preparation for the procedure she requested. Next, a mother accompanying her daughter was diagnosed with an ovarian cyst on an ED visit and very concerned about endometriosis. We had an in-depth discussion about ovarian cysts, dysmenorrhea, endometriosis diagnosis, and treatment. They left feeling heard, educated, and comfortable with the management plan. Later in the day, I saw some of the aforementioned long-term patients, and, with enough time for some social banter, it was very fulfilling. My last patient decided to come in instead of doing a telehealth visit, and we ended up doing IUD insertion on the spot.
Of course, I reflected on why yesterday was a good day. It all revolves around time. Time to review and ask questions about the patient’s history, time to connect with patients and have meaningful discussions, time to do the appropriate thing. You need to have enough time. But, unfortunately, this is not conducive to the large medical group’s bottom line. They are all about productivity, not about what’s best for patient care. In the day and age of fee-for-service, they would much rather I generate another office visit. More visits, more RVUs. They think I should be able to see more patients per session. They think I should start earlier and stay later. And they really don’t care that I spend countless unpaid hours per week outside the office finishing medical records, answering patient emails, reviewing results, and prepping for my next day in the office.
It’s no wonder there is a mass exodus of physicians going to concierge and direct care practices. I have considered moving to a menopause telehealth practice, but I realized that I like doing procedures and variety. And I love my patients. With this in mind, my goal in my current practice setting is to accept the imperfect system and find a way to tweak my schedule to give me the time I need. This may come with a ding from the organization. And the question I ask myself is, “Does it matter?” Are they going to fire me? Not likely. Are they going to ding my pay? Perhaps. Do I care? Not sure. For now, I look forward to giving my patients what they need because they give me what I need: the satisfaction that I am doing the right thing.
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