I am a medical ophthalmologist and I have a sweet part time job staffing hospital clinic, but there is so much pressure to increase patient numbers that I feel quality is falling by the wayside. How do I balance the quality of medical care with the financial reality of needing to double book all slots to (hopefully) adjust for no-shows? The politics in this hospital are killer so I am afraid of rocking the boat too much and losing this great job that allows me to spend loads of time with my kids after school.

Welcome, MoreThanMD! Is this a Medicaid mill or just a regular mill? I ask because I don't think there is any good solution to the Medicaid problem. They just don't pay enough to make a quality practice viable.

There are definitely ways to increase one's efficiency, and I'm sure other medical ophthalmologists will know some specialty-specific things you can do. You basically have to look at everything you're doing and decide whether you can delegate it to somebody else, omit it, do it differently, or do it faster. That's all! With paperwork, for example, if you can streamline things down to a single form (on paper or computer) that needs to be filled out, which has only what you need and in the order in which you do it, that will be more efficient than multiple forms where you have to jump back and forth. Delegation can be great if you are working with competent people, but if you do not trust their work, then you will either feel compelled to repeat it yourself or worry that something important was missed. Some people limit patients to one problem per visit, but then patients are not happy because they are busy, too, and they know that it is more efficient for them to address all their problems at the same time.

This is a huge problem in medicine because people want to maintain their incomes while reimbursements are going down. Everybody is trying to figure out ways to increase volume. Some of the ways are good and creative, but others are dangerous and scary. If you feel that you are being pushed to the point of compromising quality, then it is just not worth it, IMHO. It is good to feel that you could find a different job if you needed to. Then you are not at the mercy of one employer.

the whole system in this area depends on moving medicaid pts through. They make people come back every month for their stable BP meds just because the subsidized clinics get paid per pt (and there is no difference in reimbursement from a level 2 to a level 4 visit). I was actually asked if I could do eye exams without checking vision (when I complained that just checking a vision acurately could take up to 10 minutes in a child or a non-english speaking pt).

So many of our indigent patients get no counseling, no education on their medical problems. One patient today had a crazy list of heart and BP meds, so I started trying to clean it up. She admitted that she wasn't taking her meds when she didn't know what they were for. Then it came out that she CAN'T READ, so what was happening was that her primary doc just kept adding meds thinking that they weren't working and the patient would keep whole bottles of meds in her cabinet because she had no idea why they were prescribed.

Why is the medical ophthalmologist the one catching this stuff?

I've already streamlined my EHR as much as I could. I'm actually considering getting out of clinical medicine just because I see that the trend in medicine, as you have said in your last paragraph, is to increase volume even if quality of care goes down.

Wow. I feel badly for those patients. I hope there is a way that you can either continue to do the right thing for them or find another job where quality of patient care is valued.

I don't have a magic answer, but it sure sounds like it would be a shame for patients to lose you as a clinician.

When I interviewed for med school, one attending looked up in disgust when I walked in and said "why do they keep sending me the girls? You all waste the medical education because you end up just wanting to stay home with the kids!"

needless to say, I did not attend that medical school.

But that memory begs the question: is my current disillusionment due to the economics of medicine or because I really do find I'd rather be enjoying my kids during their formative years?

my husband thinks that I'd be unhappy without the intellectual stimulation of clinic and is advising me to move towards a non-clinical position if I truly want to get out of the medicaid mills and yet still be in healthcare.

Any thoughts?

Ha!

I just met with the "big boss" for the clinics, who said "we don't encourage seeing more patients at the price of the quality of care."

oh really? Then why are patients being told to come back every month for refills of their stable BP meds, or being scheduled for a separate exam for every problem as opposed to being able to address several at once? I miss the days when you could sit down with a patient and address their diabetes AND their hypertension AND their allergies all in one 30 minute visit.

Are non-medicaid clinics mills also?

I don't work in a clinic, but since nobody else is answering, I will give my two cents. From what I hear and see, there are lots of ways to run a clinic. If the payor mix is good enough to pay bills and everyone's salaries, then it is possible to spend a lot of time with patients. Some people still do that (hooray!), and some people will still turn it into a mill situation to make more money. If the payor mix is really bad (and if there is no outside funding, such as from a hospital), then it seems impossible to stay in business without turning it into a mill.

In some large areas (like Las Vegas) there are "boutique medicine" clinics where the patients pay a premium to the clinic in return for guaranteed quick access to THEIR doc and also for a guarantee that the patient panel will remain small to allow longer patient visits.

Nice if the area's economics can support it, but what about indigent areas? Don't these patients also deserve good/complete care?

I never went into health care thinking that I would spend the majority of my time dealing with the business rather than the art of medicine.

Very difficult question! It would be good to answer yes, but good/complete care does not occur in a vacuum. Someone actually has to provide that care. You or I might be willing to earn less in order to spend adequate time with indigent people, and that would be our free choice. But there are not enough people willing/able to do that. So however deserving the patients may be, the reality is that there is limited access to that kind of care. And people cannot agree upon the solution to that problem.

My parents used to try to encourage me to go abroad to donate medical care to 3rd world countries through programs such as Doctors Without Borders or Peace Corps or similar. Back in my "wise" 20's I would tell them that I thought there was just as much need here in the USA. Little did I know just how true that was!

In med school there was a program where underserved areas would pay for school in return for 3-4 years of medical service past residency.

I do agree with you that there ARE doctors out there who would freely choose to provide care in indigent clinics for less pay, but there aren't enough established opportunities from which to choose. And it is too daunting and expensive and difficult (from a business point of view) to establish such a clinic on a small scale.

Anyone know Bill Gates? Maybe we could convince him to do something like this.

I know a physician who is currently running a "boutique" clinic (ie, you pay a yearly subscription cost, not covered by insurance, and it covers everything the office can provide - including 1 hour, same day appointments for pretty much anything). He tries to set the cost at ~the cost of basic cable (although it may be more than that, really? I don't have cable to know...), and a significant fraction of his clientel is made of people who don't have insurance through work and have some chronic medical condition that would make private insurance prohibitive on their not-particularly-high salary. So, they pay for this service and, if they can afford it, some catastrophic insurance on top. There are a number of wealthy people who just want the convenience and personalized attention as well. And he does some pro bono work on top of it all. It's an AMAZING practice. He doesn't make a lot of income compared to what I'm sure he could in another setting, but it's flexible and he loves it. And, for what it's worth, this is not in a particularly well-to-do part of the country. Just to say... it's possible!

I have a private practice which is about 85% medicaid. I feel the same way about quality vs. quantity. Medicine today has become a numbers game. The only way to make a living is by increasing the number of patients you see.

I am in a somewhat different situation, as I don't have a boss to report to. On the other hand, if I don't see enough patients, I don't make enough money to live on!

I refuse to compromise on the quality of care I give my patients. However, in Pediatrics, not everything has to be done by me! I have learned to delegate a lot. Nearly all bloodwork and throat cultures are done by staff. I have a medical assistant prep the patients for me before I come in (vitals, height and weight, set out equipment needed, etc.). I use an EMR with templates which really speeds up my charting.

I try to balance giving my patients the time they need, and moving quickly. For the most part, it works. Some patients need a lot of time, some are happy to just be seen quickly and be on their way.

Most days I can see between 30 and 40 patients between 10:30 and 6, but I do not have any breaks. Sometimes I return patient calls at night, after my kids are in bed.

I don't make a huge amount of money working this way. I could probably make more money if I treated my patients like "numbers" like some practices in this area do, but I will not do that. I would rather make less and give my patients quality care because that is what I went into medicine for.

good for you! I'm glad that you have made the conscious choice to limit quantity so that you can continue to provide quality care.

Unfortunately my specialty is so expensive to start (the equipment, and if I want to delegate, the cost of a trained staff member) that I can't create my own practice. I did consider the boutique medicine route but after cruching the numbers it just isn't feasible. It's a little late now to switch to primary care, especially since I really love ophthalmology. So I've made some changes to my hours to try to keep my burn-out low and we'll see where it goes.