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Guidance please (WARNING: LONG)

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  • mainah
    replied
    Good information Rando, thanks for your input!

    Leave a comment:


  • Rando
    replied





    Click to expand


    Thank you for your encouragement. So you’re saying that it is an inefficiency issue with me, not being able to room my own patients, enter in meds and allergies at the very least, and then have a productive conversation about their T2DM/HTN/COPD/health maintenance in 15 mins? (and be honest ). I feel like I was able to get patients in and out in 20 mins at my last clinic with good MA support, but didn’t know if that was an anomaly and my current situation is the norm.

    And that’s exactly what I ended up doing with that 500 page stack of records, and had to tell the patient “I’ll have to get back to you about that” a couple of times when she asked questions about different tests she had or different meds she had been on and why they were changed. There was no way I was going to be able to hunt down specific items quickly the way the chart was sent in the 15 mins I had with the patient
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    Well, I'm not hatton but I will chime in.  I don't think anyone expects you  to be very productive without a MA, but in your initial post you seemed kind of introspective and mentioned you were doubting yourself in addition to the other problems at your clinic.

    To give you my background I am a solo FP and employ one PA.  She sees about 20 pts a day always has at least one MA working with her, usually with access to more.  To do otherwise makes no sense since her productivity is also my productivity, and if she doesn't have adequate help she will eventually get frustrated and leave.  The MA's are responsible for the med list, rooming the pt, starting obvious labs and trying to get old records.  All pts are told to show up 15 minutes before the appt.

    So some of your your frustration is definitely warranted, but on the other hand some of what you mention is stuff that happens to everybody.  The patient you mentioned was not properly scheduled - why would a new train wreck with 500 pages of records get 15 minutes?  All new pts seeing my PA get 30 minutes (except for simple acute problems), and the receptionists have the authority to schedule 45 minutes if they think it's really complicated. But sometimes sh*t happens, the patient tells the receptionist one thing and tells you a different thing.  To me the thing to do would be to handle the patient's acute problem then tell them to make a separate appt so you can do a more complete evaluation.   Reading your initial post though you came across as kind of overwhelmed by the situation - it actually sounds like you handled things pretty well.

    Anyway good luck and hang in there.

    Leave a comment:


  • mainah
    replied




    I think you are young.  Your efficiency in seeing patients and procedures will improve with time.  I also agree with the above comment that no one expects you to read 500 pages of medical records.  Look for the most recent summary, problem list, meds etc.  If you need something specific you can hunt for it.  Have patients come early to fill out paperwork is great or even better mail it to them.  Hang in there.
    Click to expand...


    Thank you for your encouragement. So you're saying that it is an inefficiency issue with me, not being able to room my own patients, enter in meds and allergies at the very least, and then have a productive conversation about their T2DM/HTN/COPD/health maintenance in 15 mins? (and be honest ). I feel like I was able to get patients in and out in 20 mins at my last clinic with good MA support, but didn't know if that was an anomaly and my current situation is the norm.

    And that's exactly what I ended up doing with that 500 page stack of records, and had to tell the patient "I'll have to get back to you about that" a couple of times when she asked questions about different tests she had or different meds she had been on and why they were changed. There was no way I was going to be able to hunt down specific items quickly the way the chart was sent in the 15 mins I had with the patient

    Leave a comment:


  • Hatton
    replied
    I think you are young.  Your efficiency in seeing patients and procedures will improve with time.  I also agree with the above comment that no one expects you to read 500 pages of medical records.  Look for the most recent summary, problem list, meds etc.  If you need something specific you can hunt for it.  Have patients come early to fill out paperwork is great or even better mail it to them.  Hang in there.

    Leave a comment:


  • CordMcNally
    replied




    Meh forced vacation is nice too…
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    Not if you're concerned about being pregnant without health insurance.

    Leave a comment:


  • Peds
    replied
    Meh forced vacation is nice too...

    Leave a comment:


  • CordMcNally
    replied
    Don't quit that job before you find a new one.

    Leave a comment:


  • mainah
    replied
    So much good advice, thank you.

    My husband was the first one to suggest I start looking elsewhere, probably after seeing how much sleep I'm losing over it, so he is supportive. The tricky thing is that we just started the family planning process and my OB has told me he doesn't want me putting it off much longer (I'm 33) so the thought of possibly being pregnant with a lapse in health insurance coverage is daunting. We have a modest emergency fund that just decreased by 1/3 with a medical issue my husband just had with his high deductible plan and even back at full strength wouldn't last long if I were unemployed and pregnant. The other issue is being rural, there aren't an abundance of jobs around, and I don't know if moving would be the best option. My husband has a good job, he is good at it, he likes it, and though it doesn't pay well (2k/month), his employer provides housing and utilities for free, and he can eat free whenever, which has helped us pay off debt tremendously. In the 16 months we've been married we have paid off over 100k in student loan/car debt and should be debt free by Sept.

    I think the plan, based on everyone's help, is to bring up suggestions regarding efficiency and not quality issues at our next provider meeting which should be next week. If things go well, then great! If things don't go well, start job hunting, preparing for a longer commute, holding off on the family planning process, and slowing down student loan payments (I'm paying 4x the monthly amount right now) and putting more away as a bridge if needed.

    Thank you! I am appreciative of the collective wisdom

    Leave a comment:


  • Drop it into MD
    replied
    Yikes.  Not all primary care is that dysfunctional.  Sounds like you can do better.  Start looking.

    Leave a comment:


  • MPMD
    replied
    I find that a lot of providers who have efficiency issues related to charting often miss the forest for the trees or struggle with some internal compulsions.

    The EMR is a state of entropy, esp for complex patients. There are infrequent but important clinical encounters when you need to spend the time to delve deep and understand things and/or spend some time cleaning up the record but these are relatively rare.

    Your own notes are not candidates for the the Mann Booker prize, the likelihood is that they are at best going to skimmed once by one other person.

    I'm not advocating sloppiness, I'm advocating that you focus on what's important.

    All of that said, it sounds like you need a new job. Both hospitals where I have worked have had excellent and robust primary care provider networks (admittedly few APPs in those places). As a non primary care provider I am not resigned to the idea that it's a losing game.

    Leave a comment:


  • Rando
    replied
    A lot of good suggestions above.  Mine would be to focus your concerns when you talk to your boss, and think about what are the individual problems with your practice, what are systems problems, and what are problems of other people.  You then need to prioritize.  Personally I would not focus much on the problems of others (which largely amounts to practice style) as you are not likely to change them much.  If you can't tolerate the way the providers practice then you should think about working somewhere else.  Your boss should be able to help with systems problems if you convince him, especially if you can find a solution to make everyone's job easier, like having pts show up 15 minutes early.

    Not having a MA is really inexcusable except in emergencies, and I would definitely mention that.

    I doubt anybody expects you to review 500 pages of records, so make sure you are not putting unnecessary pressure on yourself.   Most of medical records today are crap, you just have to pull out the nuggets.

    Leave a comment:


  • RogueDadMD
    replied
    Agree w/above.  You need to talk with the medical person running the practice about quality of care concerns and efficiency.  My guess is they are  unaware of your own concerns but also condoning much of the current practice.  If THEY are making a substantial profit they may not be the type of doc/corporation/whatever who is going to invest in quality of care or happiness of their providers.

    If they are willing to provide you a dedicated MA, compensate you based on providing a high level of care etc, then give them some time to show it.

    That won't fix your co-workers, but the question also is if YOU get what you need, can you put up with a work environment filled with others providing subpar care?

    I think exploring a new job needs to happen WHILE you talk with the powers above.  Make sure your significant other is on board from the get-go so if you need to walk-away you can do so with support at home.  If you don't have it saved now, make sure you pack away $ so you can walk away and even go without a job for a few months if needed so you can save your sanity if things don't improve and a new job isn't waiting.

    Leave a comment:


  • Anne
    replied
    You are talking about 2 separate issues--efficiency of practice and quality of care.  If the issue was just efficiency, I would look at both internal and external ways to improve that (i.e. things you can do and things others can do).  But since you are talking about poor quality of care too, I would be doubtful that is going to change, at least from what you have the ability to enact.  I would not want to stay at a place where my coworkers are failing to follow up on significant findings.  It seems doubtful that that behavior will change.  I would look for a new job while you have the good review from this job.  It sounds like you are a very thorough and caring PA and this is not the right workplace for you.

    Leave a comment:


  • Allixi
    replied
    What you're describing is, sadly, the nature of primary care nowadays, and APPs are going to have to do ever more of it as becomes less appealing to doctors. When I used to have primary care clinic as a resident, I'd have to review charts the day before and start pre-writing my notes, otherwise it was impossible to finish during the course of a visit (granted, these were VA pts with a lot of comorbidities).

    If it helps, you're not the only one. I see what I consider to be substandard care/downright stupidity by other doctors every day of the week. I'm sure some of them feel the same way when they look over my work.

    But, it's very hard to get other people to change their behavior/practice. You'd probably go crazy if you let it bother you too much.

    I suggest you take pride in the good care for your own patients. You should let your supervisor know about your thoughts, but emphasize more concern for your own pts rather than criticizing others (unless there is some truly egregious practice). If they don't at least seem receptive, you should think about leaving.

    Leave a comment:


  • Molar Mechanic
    replied
    Is hiring hard there or are they cheap?

    In the Army positions like Doctor and Dentist are what are referred to as a "force mulitplier".  Meaning that while we don't shoot guns, we keep attrition of troops and combat effectiveness high.  For instance, my time overseas I saw what amount to 5-10 patients per week that would have needed evac to remain combat effective.  Average evac time was anywhere from 1 week to 1 month return depending if they needed to go to Baghdad or Germany.

    Why is that relevant?

    If they are not fully utilizing the productive assets of the clinic, ie providers, then they are losing money.  Medical assistant costs (I'm guessing) ~25k per year, but allows you to see 4 patients more per day at $100 per patient.  $400 per day times 200-250 work days (50 weeks @ 4-5 days per week) means the office profits no less than $55,000.  My office we actually try to have at least one surplus person per day.  There is always a benefit to having someone available to perform a task, but the real payoff is when we are out two people we are simply at our need, versus the massive stressful and expensive (reduced production) days when we are truly short.

    For Want of a Nail, The Shoe Was Lost




    For want of a nail, the shoe was lost;
    For want of the shoe, the horse was lost;
    For want of the horse, the rider was lost;
    For want of the rider, the battle was lost;
    For want of the battle, the kingdom was lost;
    And all from the want of a horseshoe nail.

    Leave a comment:

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