Direct Patient-Care Face Time (DPCFT)

Most doctors see one patient every 15 minutes. The economics of our medical system dictate this. In order to pay salaries, malpractice, benefits, rent, electricity, and general supplies, we needs to see patients at this pace. But what does that mean to us practically in terms of time management? Let's think about it... Because we all have responsibilities outside of our direct patient-care face time (DPCFT)—typing up a SOAP note, filling out prior authorization forms, reviewing home nursing orders, answering telephone messages from patients, refilling medications from pharmacies, reviewing notes from specialists, reviewing labs from the prior day, calling patients, doing referrals, and so on—those 15 minutes of DPCFT really get cut down to about 10 minutes. TEN MINUTES! That's all we get folks! No jibber-jabber here! No shooting the breeze about Mrs. Johnson's grandson. Although we want to spend more time talking about family, fishing, and fun with our patients, the truth is that we don't have much luxury to do so. And this can be stressful!

So here are three imperfect solutions that I have come up with:

1. Just run late—Honestly, I'm not good at this one. My patients expect to see their doctor on time (since I'm usually on time). But every once in a while, it good to throw efficiency into the wind, take a deep breath, and truly enjoy looking at Mrs. Jone's photo album of her pet pig (true story). 
2. Schedule 30 minute appointments—I judiciously set up 30 minute appointments. They offer a breather for me with complicated followup visits. But obviously, if I set up too many 30 minute appointments, I will not be able to pay for the overhead of our office. 
3. Split up the visit—I do this especially if the patient has multiple complicated medical problems. I often feel like a heel for doing it. But patients are generally understanding. 

Other than those three tips, I can honestly say that I don't know how to increase my DPCFT. People are constantly complaining about how the U.S. medical system is broken. And from my perspective, the most broken aspect of medicine is that I have so little time with my patients. In a traditional practice, doctor who only see 2 patients an hour get themselves fired for being unproductive or bankrupt for not meeting their overhead. It's a strange predicament that we are in.

Patients ask the HARDEST questions!

After graduating from residency, I was proficient with managing strokes, working up new onset atrial fibrillation, treating severe congestive heart failure, managing a ventilator, placing central lines, doing lumbar punctures, and treating severe diabetic ketoacidosis in the ICU. BUT, I couldn't answer these simples questions:

1. Why do people hiccup?
2. Why do I get so many cramps in my legs?
3. What do I do if the Nix doesn't get rid of my lice?
4. Why do babies spit up so much?
5. How do I burp a baby?
6. What do I do if my 8 month old baby doesn't poop in two days?

It amazes me how family practice residencies can train young doctors to be so proficient in handling complicated medical problems, and yet new graduates know so little about the intricacies of burping!

Is EMR destroying “the narrative”?

Many ERs in my area recently transitioned to electronic medical records. And so far, this has been a terrible step backwards in physician documentation. Instead of getting a concise SOAP note that gives me a reasonable idea of what the ER doctor thought (or even did), I get a vomitus of essentially meaningless word-salad (which is generated, no doubt, from doctors checking off boxes on their computers). Here is a sample which I have transcribed almost verbatim (without the patient's actual name of course):

Have reviewed chart of JOHN DOE and it is ready for final disposition. Condition at discharge—stable. Patient discharged from department. Verbalized understanding of discharge instructions. Verbalized understanding of need for followup and how to access followup care. Verbalized understanding of signs and symptoms to return to ED. Patient discharged from department. Discharge home. Verbalized understanding of discharge instructions [haven’t we heard this already?]. Verbalized understanding of need for followup and how to access followup care. A disposition has been done for JOHN DOE.

What a complete waste of paper! All I want from the ER is something like this: “Johnny has a mild otitis externa. I have prescribed cortisporin otic drops for him. Follow up with Dr. Koo in 2-3 days.” Instead, I literally get five pages of tree-killing faxes that doesn’t even tell me what was prescribed! Nice!

Now I’m sure that some of the kinks of EMR will eventually get worked out. And to be fair, there have been some small improvements recently. However, because EMR relies on doctors typing and clicking on a computer rather than dictating into a voice recorder, I’m afraid that most of the “narrative” aspect of physician documentation will go by the way of the Dodo Bird. And I am saddened that I probably will no longer get something as simple as this from the ER:

“Mr. Johnson has some dizziness. I think this is probably just from some dehydration. I have instructed him to drink more fluids and to decrease his lisinopril from 20 mg to 10 mg a day. He was advised to followup with Dr. Koo in 3 days to recheck his blood pressure. Consider repeating a Chem 7 at that time to reassess his mild renal insufficiency.” 

Now that kind of dictation is HELPFUL, but will likely become increasingly rare in our new era of check-boxes and computer-based templates.