“I’m kind of old-school,” Dr. Seshat admits. She’s a millennial doc, finishing her Internal Medicine residency around the year 2000. Her practice straddles the old and the new. During her training, Seshat documented with a pen in a paper chart. She joined an independent group of primary care physicians in Florida. “It’s kind of funny when you’re in it, you just don’t know. I think we’re behind in a lot of ways.”
Several years ago, Dr. Seshat experienced two major changes with her practice. 1) A hospital gobbled up her group and suddenly she was one of 500 physicians. 2) Her clinic transitioned to an Electronic Health Record – not the one in use at the associated hospital. Dr. Seshat’s clinic administrator said, “Scan the last three [chart] notes into the EHR,” as if any patient’s medical history could be summarized and transferred in three notes. “I was never really a good dictater and I never dictated clinic notes. Ever. So even though we have Dragon [voice recognition software], which I’m trying to get better using, it wasn’t an easy transition.”
Seshat found the EHR to be completely inaccessible. It’s not the way her brain works. The group used one EHR for a couple years before switching to another. EHR’s are like trying to make your way around a country where you don’t know the language and have limited resources (tech support). At first, you’re lost. As you wander around, you begin to recognize a few landmarks, maybe a restroom (the medication list), maybe a gas station (the past medical history). If you’re lucky, you bump into someone who speaks your native tongue and can give you a few pointers (sharing dot phrases and exam templates). Some docs have greater facility in the new territory. Others are just trying to survive.
Now imagine being transported suddenly to a new country. You have to start all over.
Dr. Seshat was drowning in documentation. “I had to go part-time because I couldn’t do it with the documentation.” She approached her clinic leader, armed with resources from the internet on how to present her request. “I made this proposal for me to work part-time. (No, no, it’s not done down here.) I think the only reason they let me was I’d been there [in her particular clinic] so long.” Seshat cut back to three work days per week. “And at first it’s super great, but it turns out I just do a lot of work on the days I’m not there.”
The new EHR is less than optimal. “There’s still a lot of box-checking,” Seshat says. “I don’t even understand all the different score cards. We have different quality goals because we merged with another group. And there’s a Healthy Registries thing. I don’t even really know how important it is that I’m trying to do these certain things. With Counselling for BMI [Body Mass Index – a measure of obesity] I figured out it was fourteen clicks and two scrolls to enter in that I did the counselling, and that’s not even in my note! And then it wasn’t even being counted [accurately] by Healthy Registries.” She quit the rigamarole and decided to take a break from the fourteen clicks and two scrolls.
A prime example of the inefficient use of physician resources.
“I feel like I need to work at a frenzy, but I don’t. And if I keep up with my notes I’m horribly behind with my patients.” She completes her documentation at night, on vacation, on weekends. “Like literally, we went to California and I spent the entire plane ride doing my notes. I had to work the second day that we got there.”
Seshat’s greatest joy is “treating the same patients for such a long time. Even though I’m not Family Medicine so I don’t see kids, I definitely have seen generations of the same family. I really don’t see any new patients because I’ve been in practice so long. The ones [patients] that don’t like me, they’re gone. The relationship is the best part.” Ironically, these long-standing relationships make it hard to stay on time. “I can be much faster with someone else’s patients.” No need to check in about the granddaughter headed off to college or the beloved geriatric pet parrot.
I ask Dr. Seshat what she would do for a micro change, at the level of her clinic practice. “I really need a scribe. I just feel like we’re always behind the times. So I just assume sometime down the road there will be a scribe.” We discuss a remote scribe service that charges $10/patient. The physician wears a pair of special glasses so the scribe can “see” what’s going on. “I just don’t see enough people to make it worth hiring someone.”
Dr. Seshat chose to preserve the doctor-patient relationship and her own sanity at the expense of her salary. Her current compensation model is based on work RVUs [relative value units], a model that rewards quantity and not necessarily quality. “So I just pretty much try to see as few people as possible so that I can have a normal life.” Documenting for two days on vacation may not qualify as a “normal life.” “I have really great patients,” she continues. “My office set-up is good. I feel like I shouldn’t complain. It’s mostly the electronic piece, I guess. It’s the worst.”
What change would Seshat like at a macro level? “I guess better access at lower cost.” I ask her to elaborate. “If I want to send someone for a colonoscopy, I have to have them see GI [gastroenterology].” Even to request a routine colonoscopy? Yes! “It’s a complete waste of time and money for the patient.” When Seshat wants a patient to receive Zometa infusions for osteoporosis, she has to send them to rheumatology or oncology first. I’m shocked by these revelations. An unnecessary New Patient Consult costs money (for the patient and the insurance company) and generates money (for the specialist). To demand that patients needing screening colonoscopy see a gastroenterologist first almost seems offensive, like a primary care doc can’t be trusted to make the call. “I don’t know why. I don’t know if it’s a culture of distrust or a culture of old-fashioned-ness.”
Access is a huge issue in Florida. Seshat informs me that 44 counties in her state only have one insurer that accepts Obamacare patients. ”And they didn’t expand Medicaid in Florida.” Dr. Seshat echoes a familiar mental health refrain: “I feel like there are no psychiatrists.” Disparities in access are further stretched by concierge medicine, where patients with financial means pay fees above and beyond insurance in order to join a concierge physician’s panel. In essence, they pay for more immediate access to the doc of their choice.
We discuss the growing trend in the Northeast where physicians simply decline to accept insurance. “They’ll give you something that you can try to get reimbursed on your own,” Seshat says. Anyone who has ever disputed a denied insurance claim knows which patients are likely to wind up with a No-Insurance-Accepted physician.
Dr. Seshat’s longstanding relationships with patients are keeping her in the game. For now. “I want to quit my job but then part of me has that pride/guilt thing. How could I not do this? But I gotta do something. I feel lucky that I can work three [long] days a week, I mean that’s huge.”
She’s spending Labor Day completing the documentation for 34 patient visits. For the sake of accessible primary care in Florida, get that doctor a scribe!
Seshat is the Egyptian goddess of writing and measurement.