You recently told me that I have the physician’s group’s highest patient satisfaction scores. This doesn’t surprise me. I know what makes me great: I take time. I let patients tell their stories. I listen, educate and collaborate. When I don’t know something, I find the answer. I am the poster woman for “AIDET.”
Recognizing that time is finite, I strive for efficiency. I delegate. I refer. I use order sets. Yet when the systems fail so often, I am faced with a moral dilemma: Do I use my finite time to ensure that patients receive the care they deserve or enter sufficient data for the recompense I deserve? And if I pour all my time into patient care during business hours, then spend time after hours documenting, when do I eat, sleep, or do anything non-work related? (Incidentally, I am writing this at 7:00 p.m., and I’ve not had a meal or seen my family yet today — which is typical).
A recent study showed that for a primary care physician to deliver the quality and quantity of preventive, acute, and chronic disease care required to be profitable, she must work for over 26 hours per day. Add in any personal time, and the impossible math becomes even more absurd. Unfortunately, although critical thinking and teaching are crucial aspects of healthcare delivery, those functions don’t translate to dollars. Therefore PCPs must take shortcuts, understanding that our financial solvency depends upon our quickly clicking the right boxes and signing evermore encounters.
Meanwhile, staffing shortages, high turnaround, difficulty obtaining records, referral delays, walk-ins, emergencies, etc., render each day virtually un-plannable. Case in point: I saw a patient for a routine lab follow-up. As I reviewed the results with him, he disclosed that he has been feeling more depressed lately, which he attributed to sexual dysfunction. He requested that I speak to his wife about this privately. When I talked to her, she started crying, stating that she was afraid of her husband. His behavior had become more erratic and threatening. Upon learning that he had a stroke at another facility (it wasn’t in his medical history; I never got those records), I suspected vascular dementia. She asked: What are my options?
I had started that encounter by placing orders for repeat labs and medication changes. Suddenly I had to pivot, not just in my documentation but in my thinking. What are her options? Who do I even ask? My practice manager is out; my nurse is out, and they probably don’t know either.
Meanwhile, the clock is ticking.
Three other patients are waiting in rooms, and four more are in the lobby. I noticed that the MA roomed a walk-in before a scheduled patient because of a miscommunication between her and the receptionist, so I’m considering how I will approach educating my staff and apologizing to my patients.
Epic alerts me that two patients have called with urgent requests, and 20 lab and imaging results just came in, several critical. A drug rep is in the hall, requesting that I sign off on some samples we desperately need but don’t have time to hear his spiel about. The NP approaches me about a patient with a complex condition that she’s never managed before — should she order X or Y — and when? The other MA ran an EKG, but it printed out incorrectly, and she doesn’t know how to troubleshoot. Suddenly a patient is having a seizure in the lobby.
All the above transpired in a 20-minute timeframe.
“Tell me, Brenda, at what point do I sign that first encounter?”
Heck, when do I even figure out what my plan is?
Here is what I did: I nimbly utilized the limited resources I had at hand to make timely, sound medical decisions. Then I spent my entire lunch hour correcting well-intended but inaccurate documentation made by the MA and med student, completing the morning encounters as more and more results, phone calls, MyChart messages, and staff questions flowed in. (Naturally, I saved most of the non-RVU-generating work for “later;” i.e., after business hours).
No time to eat, rest or communicate meaningfully with a colleague. Yet despite all that effort and sacrifice, my total open encounter count grew that day because I left after only spending one evening hour on administrative tasks. The next day was full of even more patients, including some of my staff and their family members. I reflected that I hadn’t seen my own daughters in a couple of days; they are typically asleep by the time I get home.
So what’s the punchline? Four hours of admin time on Friday afternoons isn’t nearly adequate in a growing underserved practice like mine. Perhaps it suffices in practices with well-established or healthier patients, well-trained staff who are consistently present, and physicians who don’t spend as much of their day routinely putting out fires. However, I need at least two hours per day M-Th, in addition to the four hours I get Fridays.
Until I have dedicated time during the week to tend to administrative tasks, I must work 12 to 14 hours most days just to stay afloat. If I fail to work at least 12 hours per day, my in-basket accumulates, invading weekends, vacation days, and future workdays. As my and my nurse practitioner’s schedules get fuller, the responsibilities increase without respite in sight. It is not sustainable.
Jacqui O’Kane is a family physician.
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