What Would You Change?

[Febrifuge]

If you love your work but don't love the system that surrounds it, I'd like to hear from you.

 

I'll be starting in primary care after about 6 years in Urgent Care, and several times I've heard from patients that my non-scheduled, walk-in, takes-as-long-as-it-takes kind of visit is far superior to what they sometimes experience in the day clinic. I recently had a patient hug me, just because I "listened."

 

I know the people working in our primary care clinic are smart and caring people, so it's not that. I've also had a glance at their schedules and sometimes... yuck. Just no. So I'm sure the 15-minute visit, and all the reasons why that supposedly needs to be a thing, are a big part of what's wrong. But beyond that, surely there must be more that's out of whack.

 

So: if you had the ability to impose one or two new rules as the administrator of a primary care group, or if you were setting out to start your own model of how clinic should be done (and money would work itself out somehow, guaranteed, for at least a year), what would you decree? How would you make life easier and better for patients and providers with one fell swoop?

[rev ronin]

1) Walk-ins or scheduled, not both on the same day.  Seriously, when I allow a time slot to be scheduled, I am making a commitment to my patient that I will see them AT THAT TIME, barring unforeseeable circumstances not under my control.  Since I take good insurance, people have a choice where to go, and I want them to understand that I treat their time with the same respect that I expect.  Walk-in/work-in appointments? I hate delivering substandard care, but it always ends up I either have to cut things out and say "Your time is up" to the walk-in, or break my commitment to the on-time scheduled patient.

 

2) Half hour appointments at a minimum, all the time, every time.  I can make as much money with 2 99214s as I can with three 99213s, and it makes my life happier and my patients just as satisfied, so why force it?  Seriously.  If I get a couple of easy appointments and am caught up with charting and whatnot, I can start working on paperwork, and faster paperwork throughput also helps improve patient satisfaction.

[Febrifuge]

Thanks, Rev. I recently was part of a Facebook conversation that featured an IM resident and also someone working for that same hospital, who tries to make Epic and workflow function better. She was saying that there tend to be little 2- to 5-minute gaps peppered throughout the day that add up to slow things down, but aren't long enough to actually use for anything useful.

 

My first thought was, um, no, I can work with a 2-5 minute gap. I mean, maybe it's just a pee break or a chance to grab a cup of tea, but dammit that time is mine, and I somehow made it available so I want to use it. Then again, I dunno, maybe having two solid 20-minute breaks would be better than 8 separate 5-minute ones... actually, no, typing it out like that I still like small chances to catch my breath.

[rev ronin]

The small breaks are to use the restroom, eat and drink, do refills, or answer patient or other clinician messages.

 

Large breaks are for charting.  If you let your schedulers run your life, they will expect you to see patients 8-5 with only one 30 minute break for lunch, and then do ALL of your charting afterwards.  That really messes with my recall, and I have to refer to my notes a lot and becomes very inefficient way for me to chart.

 

I've started trying to AT LEAST do the subjective on every note before I go in to see the next patient.  If I can, I'll do the whole note right then, but getting the subjective down allows me to rely less on a DAY'S worth of short-term memory.  If I can't even get time at lunch to chart, I find the end of my day is downright miserable as I work to fastidiously reconstruct and document every visit.

[UGoLong]

It ain't always pretty, but I sign off on my chart when I leave the room. My breaks are to follow up with patients who called with issues that the nurses couldn't handle.

[Guest Paula]

30 minute visits are what  I have and honestly, for the most part work out.  BUT.....the brand new elderly patient, new to the system, with a long list of medicines that the MA has to log in, will take 20 minutes of their time, leaving me 10 minutes or less to examine, diagnose or treat a patient.  

 

I do not get formal 30 minute breaks (oh wait, yes I do, but usually the slide in extra visits from a walk in patient, delays all my scheduled appointments do i work thru lunch....not happy with that...). 

 

I have learned to cut and paste the HPI from my MA (who does a great HPI) into my note, and add any needed details, then I type in ROS quickly as I am asking, and end of visit do the billing/coding before seeing next patient.  That way when I go back to finish my chart I can remember what the visit was all about.  

 

If I could impose a rule it would be absolutely no "quick sick" visits as that is a misnomer, and please, let me eat cake. 

[Febrifuge]

It ain't always pretty, but I sign off on my chart when I leave the room. My breaks are to follow up with patients who called with issues that the nurses couldn't handle.

I get that this is a strategy you've settled on, but is it how you would ideally like things to be done?

 

I've never managed to become comfortable with a lot of typing while with the patient - or at least not during the H&P. I do add a couple of paragraphs to the take-home instructions at the same time I'm talking through them with the patient at the end of the visit, but my note is always later, and always way more detailed than what I could write on the fly with the person sitting right there.

[Febrifuge]

30 minute visits are what  I have and honestly, for the most part work out.  BUT.....the brand new elderly patient, new to the system, with a long list of medicines that the MA has to log in, will take 20 minutes of their time, leaving me 10 minutes or less to examine, diagnose or treat a patient.  

 

I do not get formal 30 minute breaks (oh wait, yes I do, but usually the slide in extra visits from a walk in patient, delays all my scheduled appointments do i work thru lunch....not happy with that...). 

 

I have learned to cut and paste the HPI from my MA (who does a great HPI) into my note, and add any needed details, then I type in ROS quickly as I am asking, and end of visit do the billing/coding before seeing next patient.  That way when I go back to finish my chart I can remember what the visit was all about.  

 

If I could impose a rule it would be absolutely no "quick sick" visits as that is a misnomer, and please, let me eat cake.

 

So not to put words in your virtual mouth, but it sounds like if you could guarantee a really awesome history from the rooming staff, that would be a system and flow thing that would help? I agree.

 

And UGoLong - you mentioned "issues the nurses couldn't handle" as a reason to have to break away and catch up on calls. So, what if the nurses had better training and rock-solid protocols and standing orders to follow, so they could handle more stuff in the first place?

[rev ronin]

I've never managed to become comfortable with a lot of typing while with the patient

In my practice, we have no computers in the rooms.  I just have note paper.

[GetMeOuttaThisMess]

I go in, make mental notes, come back out to my laptop, and enter default exam settings and shortcuts under plan after free texting history.  I've got a favorites listing with sub-types for Rx. categories that I auto fill/transmit.  It helps to see snot/cough predominantly since the exams are usually identical (everyone noted the pharyngeal injection due to acidity of post-nasal drainage, correct?).  If it is a "two-fer" I'll take a stenographer pad in and make pertinent notes since both usually have the same thing, but at the same time to keep individual findings separate since I won't remember 5" later.  Remember the golden rule, the number of people presenting with the same complaint is inversely related to the severity of the overall illness.

[Reality Check 2]

Today - I would change everything --- I would buy a coffee hut and work it myself.

It is Monday - and it is sucking.

 

I am trapped in a system with 10 minute and 20 minute appts - YEP - 10 minutes for a UTI, strep, sick visit, even a single med check. IT SUCKS.

20 minutes for a well child and MAYBE 30 for a complete physical.

 

It has always been this way and the 2 old retiring docs ran it like hell and saw 27-30 patients a day. They also handed out benzos, ambien and hydro like candy and didn't use enough metformin for anything.

 

Today is a rough day.

 

I want my 15/30 min appts back and I want some control over how it is done. It simply doesn't happen in FP where I am.

 

I would love to finish my appts after each patient but that ain't happening either.

 

Currently have someone who came in with urinary complaints but can't pee because he went before he left the house. DUH!

 

Sick visits out the yang and no one is REALLY sick. It is spring - welcome to rhinitis.

 

Then, the 20 minute patient I have never met who is 15 months behind on diabetic labs, doesn't check glucose, has chest pain with exertion and a laundry list of other issues.

 

MY IDEAL would be no more than 16 patients a day - 8 in the morning, 8 in the afternoon - whatever they have.

CLOSED doors at lunch - which I have and at least one actual RN in the building to supervise the MAs - or at least an LPN.

 

My other ideal is unattainable. Common sense.

 

Yep, it's Monday