Interested in learning how others are dealing with increased cries for "physician productivity" in the outpatient setting. As an employed physician, this seems to mean "seeing" as many patients as possible as quickly as possible, leaving a huge pile of unreimbursed work to be done at the end of the day by--me, as all salaried and hourly help has checked out at 5pm sharp.
At the same time, my "bonus" is based on how satisfied patients are. So we double book patients, are told we must accomodate late patients because we "need the numbers" and bend over backwards to take care of patient's needs via phone, email, etc., only to be greeted with "Satisfaction Survey" results from patients who regularly miss appointments, come late and ask for/demand free care complaining that they had to wait 30 minutes. People call 5 times in a single day asking for refills and are upset when I don't get to it until after 5pm (because I'm seeing patients all day), causing them to rank us low in "Sensitivity to Patient Needs" which prompts more lectures from Administration (on my lunch hour or pre-clinic prep time, of course) about how the doctors need to work harder to bring up our scores.
I am so disheartened at the lack of respect for physicians as professionals, my personal inability to effect change in a broken system (at least so far), and quite frankly the selfishness of some patients (do they see the other 20 people in the waiting room who need care too?) that I am just about ready to give this up. I don't need constant ego stroking--just some recognition that good doctoring takes time and thought and meaningful interpersonal communication to build a trusting relationship. I certainly am not given adequate time to develop effective relationships with my patient, nor acknowledgement that just as all patients are different and can't be squeezed into a 10-15 minute time slot, all physicians are different and can't see 20 non-acute patients in a half day (mainly time-consuming well-woman checks and management of multiple chronic illnesses for which I am reimbursed less in the long run than a string of AC patients) and retain any shred of sanity.
I've read with great interest the posts about alternative practice models or careers for physicians and am starting to look into alternatives, but I'm not ready to give up clinical practice just yet, as burned-out as I may sound/be. Any thoughts on what helped you deal with the chaos of our current medical system would be appreciated. Not ready to "go solo," but there has to be enough of us that want a more humane way of practicing Medicine that we should be able to come up with a better model.
YOU MUST JUST SAY NO TO THE RIDICULOUS DEMANDS. AND DO NOT OFFER TO TAKE LESS PAY FOR CONTINUING TO SEE THE SAME NUMBER OF PATIENTS. OF COURSE WE HAVE RIDICULOUS AMOUNTS OF WORK TO ACCOMPLISH IN VERY SHORT AMOUNTS OF TIME WITH EACH PATIENT. AND WE ARE BEING GRADED (AT LEAST HERE IN MASSACHUSETTS) BY ALMOST EVERY INSURER ON WHETHER WE MEET ALL THE QUALITY OF CARE BENCHMARKS. SO IF YOU FAIL TO COUNSEL YOUR PATIENT ON HIS BMI, WELL THAT IS LESS REIMBURSEMENT FOR YOU OR YOUR PATIENT WILL HAVE TO PAY A HIGHER COPAY BECAUSE YOU WILL BE A TIER TWO OR TIER THREE PHYSICIAN. NOT TO MENTION THE PATIENT SATISFACTION SURVEYS! ALL OF THIS TAKES TIME! SO IT IS EVEN MORE IMPERATIVE, NOW THAT OUR PROFESSIONAL REPUTATIONS ARE AT STAKE, THAT WE HAVE ADEQUATE TIME TO SPEND WITH OUR PATIENTS! YOU MUST STAND UP FOR YOURSELF IN THIS. IF YOU AND THE OTHER PHYSICIANS CAN PRESENT A UNITED FRONT TO THE PRACTICE'S ADMINISTRATION IT WOULD BE BEST. IF THEY VALUE YOU, THEY WILL WORK TO PROVIDE A SATISFACTORY WORK ENVIRONMENT. IF NOT - HEY - THERE ARE PROBABLY OTHER PRACTICES OUT THERE WHERE YOU WOULD BE VALUED. YOU DID NOT TRAIN FOR MANY YEARS WITH NO TO LITTLE PAY TO BE TREATED LIKE THIS. YOU ARE NOW GOING TO BE EXPECTED TO WORK MORE FOR THE SAME PAY? HELLO! I CAN NOT HELP BUT FEEL THAT WE ARE SOMEWHAT CONDITIONED TO ACCEPT SUCH POOR TREATMENT BECAUSE OF THE LONG HOURS WE WORKED AS RESIDENTS. IN A WAY, WE WERE MALTREATED AND UNDERPAID THEN SO WE ARE KIND OF USED TO IT. BUT, IT IS NOT OK! JUST WONDERING, DO YOU WORK FOR AN HMO GROUP? OR A PRIVATE PRACTICE?
That sounds like a horrible practice situation! You are employed, so you have no control over the unreasonable work conditions, yet you are held solely responsible for the patients' satisfaction? :scratchchin: It sounds untenable to me.
I recently read a book by another MomMD member (tonim), which talked about how some people resorted to scheduling dead patients in order to slow down the pace! (I am not recommending that you do that, though!)
This is not my specialty, but there are a lot of alternative practice ideas cropping up, and not all of them are solo. There have been a lot of threads about that on Sermo, and here is one on MomMD as well:
Thanks for your comments. I have an interesting practice situation--I essentially have a private practice within an academic training program. So I am employed by a large hospital group and affiliated with a university, which, I suppose is part of the problem. Private practice alone is hard enough (and I'm mainly clinical), then to add teaching responsibilities into the mix without being given acknowledgement that this impacts your clinical productivity or time to attend to the non-clinical work you're expected to do--well, you get the picture.
I agree that we are conditioned to tolerate maltreatment from medical school forward. A lawyer I know once asked when we as medical professionals lost control of our own fate, not to mention practices. I told him it was while we were looking the other way, nose to the grindstone, trying to do the right thing by focusing on providing the best patient care possible often times at great sacrifice to ourselves and our families. We are good at deluding ourselves that we are taking the "high road" by doing this and not worrying ourselves about business or administrative matters, but it turns out that by eschewing business savvy for patient care, we've actually managed to have quite possibly made things worse for our patients and ourselves.
I suppose I'm just not particularly hopeful that I'll be significantly more valued anywhere else. Sadly, several physicians whom I greatly respected within our practice left without fanfare after our group put up a "united front" to our administration and were basically told "sorry, this is the way it is. No concessions." At that point, I looked into a few alternate private practice positions and was disappointed to find that "part-time" is still a foreign concept to many employers and that the same productivity and satisfaction survey chatter was just as prevalent in other systems. The main reason I stay is that I generally enjoy my interactions with patients when I walk in the room, I have wonderful colleagues and I'm part-time no questions asked. Admin knows that most of us would feel bad about "abandoning" our patients and plays shamefully on this sentiment, in my opinion, running us on a treadmill "for the sake of the patients" and convincing us that "we don't like it either, but everyone is doing it this way so we have to too."
I read an article in one of the many free medical journals that come across our desks recently that described current system "quality improvement" practices such as publicly posting physician scores, productivity ratings and patient satisfaction scores as "Covert Rationing," meaning bad scores don't necessarily prompt better care. They may just prompt you to get rid of high-risk, complicated patients so your scores look better. Your scores go up, the patients go somewhere else, and the new physician's scores then go down and the patient is shuffled out once again, receiving low-quality, fragmented care in the process.
It's a sad day when professionals who took the Hippocratic Oath see no problem with refusing to take Medicare or Medicaid patients because reimbursement is so low and/or these patients have more complex/challenging problems that not only one isn't paid to address but can bring down your "scores." I understand the reason--you have to pay loans, support a family, etc.--but why didn't we all rise up in protest as morally responsible physicians in the first place and point out that such dismal reimbursement is essentially socially acceptable marginalization of an entire group of people who need health care just as much as anyone else? It is just unbelievable to me that it has come to this, and that I am a part of it.
I agree with this discussion, and by the way, I have read your input, kpzr, in other threads and want to root you on in your approach as you describe it. I also can't believe that we train in medicine to do all this office/secretarial paperwork.
I don't know if this is helpful here, but I want to offer it. I think that many people go to the doctor for general reassurance, rather than specific health issues, and that we are not able to meet that need in the current environment. (and I would add that today's society is ill, we are all sick from what we read about our country in the news everyday, by the demands of the pace and expense and stress and misplaced priorities of American lifestyle) I am a subspecialist in a field that provides a counselor available in clinic to patients. This is where I'm going, that I refer almost all my pts to her, and it is a relief to me, that the talking I would usually do myself, about the difficulty of life with health problems, can be deferred to her, and to know that their visits with me are often preceded or followed by time with her.
and I think alternative medicine offers similar reinforcement, acupuncture, massage etc. We recently had a pharmD in our clinic, and that was helpful too, just another provider besides myself to extend the visit and talk, and of course offer valuable input in taking meds/scripts.
We just had a representative from a new pilot program come and talk to us about a new concept called "The Medical Home". Sounds great in theory. Paid per patient per month, not by "the numbers crunch". Not too sure how well it will be received, but from his talk, Congress is already on board. There are about 50 pilot programs throughout the country. It entails a lot in the way of ancillary staff to help free up physicians to do "physician work". I haven't had time to look into it too deeply and frankly, until it takes wheels, not going to.
Sorry I don't know how to paste where you can just clink on it. Our hospital is going to be one of the participants in the project. Just thought some people might be interested in taking a look. Almost sounds to good to be true.
"Cure sometimes, Care always" <br />Dr. Robert Fogel. <br />"Go confidently in the direction of your dream. Live the life you have imagined". HD Thoreau