Asking primary care clinicians to work harder isn’t a solution

“Sorry Dr. Pelzman, just one exam room today.”

This is how our medical technician greeted me as I arrived for my Wednesday morning practice session earlier this week, with a full panel of patients on the schedule set to see me over the next few hours.

Most of them were my own patients, well known to me, but a few were new patients who had been referred by colleagues in our institution, and a few were patients who had been lost to follow-up for many years who were coming back to reestablish care.

Heading into the morning, that schedule didn’t cause me much trepidation, and it looked like it would be a fairly routine morning.

Until I heard those words about room availability.

In our practice, a large combined faculty and resident site with 28 full-time clinician educators and 130 internal medicine residents rotating through, space, as you can imagine, is often the final frontier.

Everyone’s battling for it, everyone wants a little more, no one has much to spare.

Often we sneak someone in, an urgent add-on patient, when no one is looking.

For most of our practice sessions, the attending physicians are assigned two exam rooms, while the interns and residents get one room each per session.

The attendings get 20 minutes per appointment slot, and we often overbook patients onto our schedules, so the buffer of having multiple rooms can be really useful.

To be honest, I’ve never really quite gotten into practicing in multiple rooms at the same time. I have friends who practice with three exam rooms, and they will go from room to room to room and back again, seeing patients and then moving on to the next one while other staff members attend to particular tasks that patients may need completed during the office visit.

For me, the second room is really most useful if, for instance, we discover that a patient needs an electrocardiogram done while they’re here, and this can be done while I move on to the next patient on the schedule in the room next door.

Otherwise, it never really made sense for me to have two patients in two rooms at the same time, since I can only really be in one room at a time.

But when I heard on Wednesday that I only had one room, I started peeking ahead at the day’s patients, and started making decisions in advance about what we were going to need to do.

It didn’t look like there were any pre-ops on the schedule, so I didn’t think electrocardiograms were going to slow me up there for these patients, and while some had medical conditions such as coronary artery disease or hypertension that might warrant an electrocardiogram, I didn’t think this was going to slow me down too much.

But the best laid plans are often those that go the farthest awry. One patient who feels poorly, who we need to get some IV fluid into and let them hang out for little while, or someone sick enough to need to wait for paramedics to take them to the ER, is all it takes to put your day an hour or two (farther) behind.

As part of our institution’s patient-centered initiatives, we’re looking at more and more ways to try and increase access for our patients. One of these involves increasing efficiency, finding ways to schedule providers better, schedule patients better, decrease no-show rates, and take advantage of rooms that may be lying fallow.

When trying to investigate this further, I looked over the templates that our schedulers build out week to week of all the providers in practice and all the rooms at our disposal.

Glaringly, and not so surprisingly, not many people want to be in practice on Friday afternoons, so there seem to be quite a few open exam rooms there.

There is a certain amount of built-in inefficiency in our schedules, as residents get changed at the last minute to cover an inpatient service or a fellow resident out for interviews, and faculty have to reshuffle their schedules to cover wards, meetings, and other administrative responsibilities.

And on Thursday mornings, most of the faculty and residents are in academic conferences, so we “sublet” some space out to subspecialists who need extra places to see their patients.

Otherwise, there’s not much empty space on the schedules, and so trying to figure out where to increase efficiency to fit in more providers and more patients is going to continue to be a challenge.

We are currently collecting data on volume of patients, no-show rates, providers who are seeing too many patients or too few, and trying to pick up patterns to see where we might make inroads into using the space we have to its maximum advantage.

But no matter what we do, we can’t take an already packed schedule and simply make those who are already working really hard work harder.

If we double everyone up on exam rooms, then patients and doctors are both going to feel even more rushed and squashed, and more and more people will end up at the end of the day feeling that the doctor didn’t have time to listen to them, and the doctors will feel that they didn’t have time to address the needs of their patients.

Our Saturday practice and other possible expansions on the weekend may end up improving access for a little bit around the margins, as well as providing a nice stopgap service to our patients, but it’s not going to be the be-all and the end-all for access.

Sure, we can open up before the sun comes up, and stay open well past dark (we already have practice evening hours three days a week), but we can’t just ask those that are already working really hard to work even more.

And no matter what we end up doing to improve our efficiencies and our access, we need to make sure that we don’t lose sight of the important role of not only caring for our patients, but of educating the next generation of medical students and residents who are looking to us to see whether a career in primary care is right for them.

We all recognize that there are budgets that need to be balanced, and belts that need to be tightened, but sometimes an investment in creating a kinder, gentler environment with a whole team of support built up around the providers and the patients is going to give you more bang for your buck.

You fill in the blanks.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.

Image credit: Shutterstock.com

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