Our health care system is a mess, and while many of us fighting in the trenches and taking care of patients are working to make things better (despite the best efforts of much of the rest of the system), the challenges and our ability to overcome the barriers that stand in our way often seem insurmountable.
Take, for example, a recent office visit from one of our patients, typical at our practice. Overbooked onto a schedule already packed full of patients, he had called up requesting a same-day appointment with urgent issues he needed addressed.
Those of us who have done this for a long time have always found ways to squeeze these patients in, to make this work, to try and keep our patients out of the emergency room. But even in the best of worlds, this type of visit can challenge us all.
The big list
Once in the exam room, the patient brought out a list. Now personally, I love when patients bring notes and lists, either on paper or on their phones, sometimes it helps structure the visit better, helps us get through their agenda so we can get to ours, and often prevents that hand-on-the-doorknob, “One more thing, Dr. Pelzman …”
But as this patient pulled out his list, I realized this was not a single issue, a “sore throat,” “what’s this rash,” “can you remove these sutures,” “my ankle hurts” kind of visit. No, this list had 17 items.
In the best of scheduling worlds, we get 20 minutes for appointments, but with overbooking, patients arriving late for appointments, slowdowns caused by computer and insurance issues, it’s rare for us to get a full 20 minutes to sit and really take our time, figure out all that’s going on, and get through their list and ours. If things are running smoothly and working at maximum efficiency, these 20 minutes would give me about 71 seconds per issue for those 17 issues.
I’m pretty good and pretty efficient, and often when patients bring a list like this there are things you can sort of group together, collectively figuring out what might be caused by a single thing — what’s the forest for the trees. A quick lab order, some gentle advice, something to try at home.
But sometimes, there are enough big items on that list that you can’t do justice to them all. And after finally wrapping up as many of his items as I could, I was sort of jolted to remember that I had a bunch of things that I needed to get to for this patient, some health issues and health maintenance items that needed attending to, that would serve him better than spending those scant minutes (seconds?) on the items on his list.
Checking all the boxes
There were a number of screening issues he hadn’t gotten to, vaccines he has put off, medications he wasn’t taking regularly, self-care that he was avoiding, and medical conditions that were not optimally managed either by myself, by his specialists, or by him.
And all of these items were the things that are going to lead to the system telling us we’re not taking good care of him. A letter from the insurer that says he’s not filling his statin regularly at the pharmacy; what am I going to do about it? Or a report on screening metrics for which his failure to get his colon cancer screening completed leads to yet another demerit for my practice.
And, he shows up on a quality improvement project as a big “no” under health care proxy, since no record of this exists in his chart, as he has repeatedly not completed the form we’ve given him or engaged his family members on what he wants to have done later in life.
So all the things that all of us are doing to try and innovate and advance primary care, to fix the broken health care system, are all of these moving the dial, making things better, or are we just continuing to inundate the patients and providers with things we’re not doing well? “You’re doing it badly, so do more of it and do it faster.”
It’s time we ask ourselves, “What do we want our health care system to look like; what’s the best it could be in 5, 10, or 20 years from now?” Yes, there are going to be lots of bells and whistles in the electronic health record; yes, we are going to have automation and robots helping us; and yes, artificial intelligence will peer into the lives of our patients and inform us how to take better care of them. But can we get there from where we are, or do we need to scrap the whole thing, and finally admit to ourselves that in the fee-for-service model with diminishing returns, cramming more patients in the schedule is not the answer?
Getting to a good place
Health, wellness, prevention, and thoughtful care of existing conditions are the ultimate goals of any rational and equitable health care system. Clearly, what we have is not doing a great job of helping us and our patients get to any of these.
Forcing doctors to function in an environment where they are clicking boxes and creating elaborate notes that serve only to satisfy billers and auditors, continuous regulatory requirements and online courses we need to complete, the burdens of maintenance of certification, and endless regulatory and insurance barriers have created a toxic environment in which, not surprisingly, we are discovering that everyone is burning out in some fashion or another.
I love my job; I love coming to work every morning; and I have loved taking care of patients and teaching outpatient medicine for the past quarter of a century. We have to start to work together to create an idealized manifestation of the vision of this best practice for health care for our country, our patients, and ourselves. Only then will we be able to inspire the next generation to follow in our footsteps, to pick up the mantle of primary care; subspecialty, medicine, surgery, radiology, psychiatry, and all the rest. And only then will we be able to give our patients the attention they need to get to everything they want to address, while still allowing us to take the best care of them.
Or else our 2 cents are only going to add up to 71 seconds.
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