Anne Lippin

“Some days I feel like I have the best job in the world.”  Dr. Vishnu works at an FQHC-designated clinic in California.  She calls me between the demands of work and parenting.  “We are invited into people’s intimate lives and it really is an honor.  I’m trying to hold that as the sacred trust that it is, in the midst of the uphill battle with the system as it is.”

I’m curious to learn her perspective.  FQHC-designated clinics qualify for government grants, malpractice insurance, and reimbursement for taking care of Medicaid patients, in exchange for caring for anyone who walks in the door.  Vishnu’s understanding is that her clinic is paid per patient visit, not for the number of problems you address or the specific tests you order.

This is very different from the production model of reimbursement and compensation previously described in this blog.  Vishnu has been there, done that.  She was perfectly willing to work hard.  Her one request was that she be allowed to put a few holds in her schedule, small blocks of time with no patients, so that she could adequately address the needs of complex patients and stay relatively on-time.  “Running behind isn’t respectful” of patients.  The health system where she worked declined to allow her any scheduling control.  She left.

Now Dr. Vishnu is on straight salary.  I’m wondering if maybe this is the answer to the escalating productivity expectations described by Dr. Apollo in my last post.  Nope.  When many health systems switched to twenty-minute appointments, Vishnu’s clinic followed suit.  “There’s no room in the system for phone calls, emergencies, getting lab information back to patients.  And now patients can electronic message you,” generating more requests demanding attention in an entirely rigid schedule.

“When do you do the preventive medicine, the holistic approach?  You either run late [with twenty-minute appointments], or you deal with one issue and then the patient has to come back.”

From an organizational perspective, bringing the patient back may have financial advantages.  Vishnu, on the other hand, is acutely aware of the logistics faced by many of her patients as they try to make it to even one appointment.  Arranging time off from work, child care, transportation.  Missing work might mean losing income or even losing their job.

“There’s this constant push to do more,” Vishnu continues.  “Every doctor that you’re seeing is doing their charts at home.”  For each clinic day, she generally has two hours of work left to do at home.  Or she’ll stay at work for an extra hour plus work through her lunch in an effort to complete her chart documentation.  “And that’s actually really, really good compared to most of my colleagues.”  Her colleagues routinely stay up till 1 am or get up at 5 am (before the kids awaken) to finish charting.  “Basically we have an army of health professionals who are sleep-deprived, having relationship issues, and who aren’t doing all the healthy lifestyle things we preach to people to do.”

“It’s such a farce,” she says of the every-twenty schedule.  Seeing the patient, making an assessment and plan for their conditions, documenting the visit in the electronic health record, entering all orders for tests and consults, and being ready for the next patient.  And still connecting on a deep interpersonal level in the doctor-patient relationship.  “Nobody can really do that.”

Dr. Vishnu is fluent in Spanish, an incredible asset for any clinic.  Imagine conducting a patient visit in Spanish and simultaneously trying to type in English into the computer.  The visit is twenty minutes.  Maybe you, the reader, have been handed an AVS (After Visit Summary) at the end of an appointment, with a list of your diagnoses as well as a short-term plan for your health.  There’s no easy way for Vishnu to generate a bilingual AVS unless she literally types everything twice.

“I don’t write in full-sentences,” Vishnu says.  She charts in sentence fragments and the charting short-cuts called “dot phrases.”  “The choice was be efficient or pay for it on the back end.  My goal every day is not to have to open my computer when I get home.  Bad weather can be a blessing because fewer patients come in and I can get caught up.”  Bad weather in California is a rare occurrence.

“It’s so demoralizing,” this leaching of work into family life.  “Not to have time with my partner, an hour or two doing charts on top of my long hours at clinic.”  Vishnu caught some heat from her boss who wanted to know why she wasn’t checking work emails and attending meetings on her day off.  She stood her ground.  Her colleagues cover each other for urgent matters on off-days.  “There is nothing that’s going to happen regarding my patients that I’m the only one smart enough to take care of.  We need to rely on each other more.  It’s this idea that we are these superheroes [who should simply deal with everything] – it wasn’t good for small-town docs years ago and it’s not good for us today.”

She talks of recent computer upgrades, where physicians were told, “’In your spare time you can play around with this.’  Imagine another profession where the tool you use is changed and you’re left to figure out how it works by yourself.”  Doc meetings (unpaid) often happen before work or during lunch.  “The ability to have any work/life balance is eroded away.”

I ask Vishnu what change she would make on a micro level.  “Other than removing my boss?”  We laugh and she goes on to describe a recent medical encounter.  Dr. Vishnu had taken her mother to see a specialist and noted the impressive array of support staff: two PAs, an MA, and a nurse enabled the doctor to be optimally efficient.  At Vishnu’s clinic, they ususally have an  MA for each provider and an LPN for ten doctors.  “The amount of stuff that could be done by somebody else but isn’t, due to budget, is incredible and highly inefficient.”  She might be able to make the twenty-minute appointment work if she were adequately supported.

The macro change is easy.  “I do not understand why we don’t have nationalized health care.  We spend so much money on administration.  I see so many people who have no insurance.  And half the time the people with insurance are as bad off as the people with no insurance.”  Vishnu recalls one of her patients, a 40-year-old with cancer.  Despite an alarming symptom, he put off seeing the doctor for three months so that his visit would go toward the next year’s deductible.  “People leave things until it’s too late,” when faced with the financial reality of their insurance deductibles.  Why should a resident of a “developed” nation have to choose between paying for her prescriptions or buying her groceries?  I shared this frustration when I worked in clinic.  I naïvely thought patients should be able to make their medical decisions based on my medical advice.

“I think we need to go back to the point that practicing medicine encompasses  knowledge and skills and a relationship,” Dr. Vishnu says.  “The relationship is paramount, the care team is paramount to promote health.  We don’t have systems in clinic or a society that supports that.  We are disease-focused.”  In Vishnu’s nationalized health plan Nirvana, each patient would have a baseline ninety-minute visit once a year, a preventive medicine and health assessment visit, where the physician and patient could sit down and discuss goals for health.  “It’d be me and Michelle Obama in a room together [with the patient] and I’d do the health things and she’d get ‘em moving.  And feed them kale.”

I ask Vishnu to describe her greatest joy as a physician.  She talks about the satisfaction of working with her patients to make healthy changes such as quitting smoking or beginning an exercise program.  “I also love seeing kids for well-child check-ups, healthy kids who are with competent parents.  Seeing a nine-month old for a healthy baby visit, assuming they have competent parents, can fix a pretty bad day.”

Vishnu recalls an episode from a few years ago.  She picked up her own child at daycare after work and was immediately called in to deliver a baby at the hospital.  “I was delivering this baby and the aunts of the patient were holding my son.”

Family medicine at its best.  People in community, taking the time to care for each other.

Musical Moment

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Vishnu is a Hindu God, the Protector of humanity.  He is generally depicted with four arms.  (I’m thinking extra arms could really enhance physician efficiency and improve work/life balance.)

I reconnected with Dr. Apollo (a pseudonym) after  my recent Oberlin College reunion.  I’m a doc, you’re a doc, let’s chat sometime.  He agrees to be interviewed after reading my blog post on physician burnout.  “Oh my gosh,” he says.  “This is exactly what we talk about!”  Scheduling the interview turns out to be a minor challenge.  Apollo and his wife have been trying to update their will for four years.  The night before we chat, Apollo spends the evening on the computer, finishing the electronic chart notes for his clinic patients.  Then he completes the twenty-five charts pending from earlier in the week.  He goes to bed at 6 am.

I send him a Facebook message that he reads at 1:27 am.  The next afternoon, I catch him in the car.  His wife’s driving.  For a guy who commonly gets three hours of sleep a night, he sounds pretty good.

Apollo loves medicine.  He was chief resident in Internal Medicine before pursuing a fellowship in Infectious Disease.  He wound up in a large health system in Ohio.  Germs rock his world.

Like Family Medicine and general Internal Medicine, Infectious Disease isn’t a procedure-driven specialty.  Dr. Apollo is paid for “production,” for the number of wRVUs (work Relative Value Units) generated in a day – or night.  The thinking specialties, Pediatrics and Internal and Family Medicine, pay far less than interventional or surgical specialties like Cardiology and Orthopedics.

The compensation system can’t even comprehend the complexity of the patients Apollo sees on a typical day.  Imagine the time it would take to communicate with an elderly Latino immigrant through an interpreter.  And by the way, the patient is deaf.  Add a sign-language interpreter.  What if I told you that the patient has multi-drug-resistant tuberculosis (add a boatload of protective gear) and is actively suicidal?

You have twenty minutes.  Good luck.

Life in the hospital is equally challenging.  About ten years ago, Apollo would make rounds on 6-8 patients per day, two of whom were new consults.  Now he rounds on 16-20 patients per day on top of 6-8 new Infectious Disease consults.  Weekends are grim with only one doc on service and an average census of 30 ID patients.  Apollo spoke up in defense of quality patient care.  This isn’t safe!  We need more docs!  Administration informed him that he could hire a moonlighter with his own money.

There was one day back in about 2002 when I was on my hospital week.  My census was 18, including folks in the ICU, pre- and post-operative consultations, newborns (some of whose parents requested neonatal circumcision – another topic, another time…), small-bowel obstructions, pretty much the routine spectrum of Family Medicine.  I cried that day.  I think I was standing at the nurses’ station.  Derica, one of my favorite nurses, did her best to reassure me.  It’s okay.  You’ll get through it.

Dr. Apollo is getting through it.  Sort of.  On top of caring for real-live patients, Apollo is also available via pager to whomever wants to chat.  This is a “service” that the specialists in the system provide, an unpaid service.  In procedure-driven specialties, the docs might see some procedural revenue.  In the thinking specialties, these “curbside consults” are a charitable contribution to the organization.

Let’s pretend I’m in clinic again, and I’m seeing a young man with newly-diagnosed HIV disease for his hospital follow-up.  I have questions about his medication regimen that require ID input.  In the olden days, I would ask my RN to please contact my favorite Infectious Disease doc’s office and try to get her on the line.  What would she get in return for being available to help me?  A new clinic patient.  And my undying loyalty and gratitude.  Maybe I could work her son into my schedule for his forgotten sports physical.  What goes around comes around.

Now, if I practiced in Apollo’s system, I would call a general number if I couldn’t find my MA, and request that an ID specialist call me back.  I’d ask Apollo to look at my patient’s x-rays and med list, and weigh in on a follow-up course.  I have no personal connection to Apollo.  He’ll never see my patient.  But his name is on the chart.  Welcome to liability risk with no benefit whatsoever.

On a recent Wednesday, Apollo tracked these “curbside consult” phone calls.  He spent four hours on the phone.  Unpaid.  What goes around comes back to the pocketbook of the CEO.

Ebola almost killed Dr. Apollo.  Three of his colleagues had recently left the department.  The new hire came from California and lacked familiarity with the facility, the staff, and the computers.  Ebola hit.  Who do you turn to when Ebola hits?  Your Infectious Disease specialists, duh.  In one week, Apollo pulled three all-nighters.  One day, he had eight hours of (unpaid) meetings and saw 18 patients in the hospital.

Apollo is burning out.  It’s a smoldering burn, gathering energy over the last several years.  His department continues to hemorrhage docs and the system continues to just not get it.  (Medical students and residents get it.  The applicant pool for Infectious Disease is in a three-year decline.)  Dr. Apollo took a stand last year, demanding compensation for the curbside consults, input into clinic support staff hiring, and more time with complex patients in his clinic schedule.

The organization basically said – Prove how much time you’re spending on the curbsides!  All the calls are recorded, and somewhere in the system that data is available.  Is it available to the docs appropriately asking for compensation?  No.  Clinic support staff decisions continue to be made without physician input.  In response to the need for more time with complex patients, an administrator said, “Fine.  You just can’t lose productivity.”  And suggested that Apollo add time slots earlier in the day and work through lunch.

“It feels like we have so little autonomy,” Dr. Apollo says.  On a recent day in clinic, a nurse asked Apollo to add a patient in to his schedule.  He said no, please put them in tomorrow’s schedule.  The patient was stuffed into his day anyhow.  “What did you do?” I ask.  “I just saw the patient,” he replies.  What else can he do?

Dr. Apollo recently attended a medical conference on physician burnout.  His pager went off so many times that he had to leave.  #irony

I ask Dr. Apollo about his greatest joy, if there is any joy left at all.  “I think probably it’s that there are certain patients that I do love taking care of.”  He enjoys the social justice aspect of infectious disease, particularly in regard to refugee populations.  “In the past month, every time I see a refugee, I thank them for coming to Ohio.  I say, ‘The state is so much better because you came here.’”

What recharges his batteries?  An appreciative patient.  A successful strategy to improve the efficiency of patient care.  Academic projects such as putting together a talk or a reading.

There’s no time.

The hamster wheel of productivity strips the organization of opportunities for creativity and innovation.

There’s not even room for creativity in a chart note.  The doc’s assessment winds up being a list of diagnoses instead of the thought process behind the list.  “Medicine is about storytelling.  We even comment on it it our notes!  ‘The patient is a poor historian.’  We value that!”

The story is lost.  And the therapeutic relationship suffers.  It’s “like a factory model of healthcare,” Apollo notes.  (His son concurs from the backseat.)  “I try to keep eye contact [with the patient while typing on the computer].  I can type fairly well without looking at the keyboard.”  Sometimes he glances down and finds a paragraph of gibberish.

Dr. Apollo is plotting his escape.  He’s researching other Internal Medicine fellowship options.  What time do docs leave clinic?  What’s the average number of patient visits in a day?  Would he be able to incorporate his love of infectious nasties?  Do the docs recognize their own children?  This is a bold and radical step for a middle-aged man, to take a drastic (but temporary) paycut for the promise of eventual sanity.

I ask what change he would make on a macro level, a BIG THING.  “Single-payer,” Apollo says immediately.  He cites a graph of the steadily increasing number of physicians over the past several decades, overlaid with the exponential increase in administrators.

If Dr. Apollo switches subspecialties, maybe he’ll have the time to help with the Revolution.

I ask where he hopes to wind up after completing yet another fellowship.  He’d consider staying in his current organization.  I’m shocked.  In spite of everything?  “The [redacted to prevent more physicians from flocking to this subspecialty] docs love it!  I don’t want to burn bridges.”  And he wouldn’t want to leave his home state.

Better the devil you know?

Dr. Apollo is convinced that necessary changes to the US healthcare system will be driven by patients.  I agree.  If patients understood the abusive system that gobbles down young idealistic medical students and spits out jaded, ulcer-riddled automatons, surely they would protest.  “If doctors advocate for themselves,” Apollo continues, “it’ll look self-serving.”

What then must we do?  I’m a patient.  You’re a patient.  Please.  Speak up!  Get on the phone.  Grab your computer.  Tell that CEO to stop killing your doctor or there will be no doctors left to kill.

Musical Moment

Apollo is the Greek god of healing.  And herding.  Convenient.