Where I work, we have decided some policy changes. First of all, let me clarify what “we” means. “We” is the management of our clinical enterprises, either one or both of them. I scratch my head in wonder.
Lots of people now are talking about how our relationships with our patients are so important. Well not exactly. What they say is put our patients first. What does that mean really to them? (“them” being the management I mention above in “we”)
They talk about team care, the patient centered medical home. If we (now I mean me and others actually doing the work) meet some criteria, we get more reimbursement. But is that really putting the patient first? What are those criteria?
Why is it that no one asks us who see patients what do we do to put our patients first? Why do they not take it from patients who are satisfied?
But I digress.
Our new policies:
1. We want our medical assistants to do more, facilitating what the doctors need to do. They have long templates to complete on multiple visits, much more than the “why are you here?” and its ancillary questions, blood pressure, weight, pulse, respiratory rate, and oxygen saturation (and why does a healthy 20 year old need oxygen saturation anyway? Show me the evidence. I would rather that they remember to obtain and chart the respiratory rate and oxygen saturation when there are symptoms and cause.)
2. They are to review every medication the patient is on and check them off.
3. They are to see if any immunizations are needed and to order them for me to sign
4. If it is a kid for a well child check they are to enter data from a long questionnaire the parent(s) filled out on how the child is doing medically, emotionally, nutritionally, and developmentally.
5. That is to take place before I see the patient.
6. What that means is: our patient calls for an appointment. Say they have a fever and sore throat. They get a 15 minute appointment. Say they are 80 with multiple problems. They get a 30 minute appointment. If 1-4 are completed by our medical assistants, I get about 5-6 minutes in a 15 minute appointment and maybe 12 in a longer more complicated appointment. Do the math.
7. If I take the time I was supposed to have, I get behind, running the risk of irritating the next few patients on my schedule. If I fill only the time left, I am shortchanging the patient I am seeing, who might feel they did not get to handle enough in the brief time with me. Oh and by the way, it is fraud if I bill for more.
At the same time, we are pretending that we are being a team. Don’t get me wrong. I believe in teams. I love teams. It used to be true that our front desk staff were on the team. They knew the patients when they called for appointments. They knew who they could squeeze in as an extra, who needed more time. And our patients trusted them. Now we have a call center for the whole medical center, that I will just say is not the same. It used to be true that I worked 95% of the time with the same medical assistant. The patients who call me their doctor knew that medical assistant had their back, whether it was a hug or an urgent medication renewal. We had a pharmacist and social worker who knew most of our patients and our highest need patients knew them.
That was then and this is now. Team? Why is the patient left off the team? How come they don’t know that the work of the medical assistant is part of their visit? Why don’t we schedule so that the medical assistant work can happen and I can still have the time my patient and I need to work together on whatever brought that particular person to the visit? Instead our patients are dissatisfied. The medical assistants are incredibly stressed with more to do and realizing the more time they take the less time we doctors have. And I cannot do my job.
This is just one area where not involving regular working stiffs (like me and our staffs) in policy and process development just does not work. Instead we have institutions trying to get certificates for a reductionist view of what is needed in our encounters, er, yea I mean relationships, with real people around their health concerns. Check boxes, lists of criteria…most well intentioned and could make for good patient care, but reduced to a get it done without any realism about time and skill and the imperative the patient brings to an encounter with me.
Oh well….I will keep doing what I do. The next piece may be on Intellectual Freedom, the academy (that would be places where teachers and scholars live in universities), and my institution—that is if I believe the new language in our faculty code that gives us some intellectual freedom and whether I trust that it would supersede the policy of the Medical Center.
Moments 
This is on my mind nearly every time I go to work. I think they have this standardization thing all wrong. Sure, it may be best practice for some institution on the east coast. Their big ideas and shortly tested experiments demonstrate numbers for a few and have not been watched over a long enough time to visualize an accurate number of patients falling through the cracks and receiving bad service. The standardization of medicine may increase revenues but that is not necessarily what all providers strive for. I think our country is at fault for this. It has institutionalized health as a company rather than a virtue.
Yea topshelf, I agree.
The PCMH is, alas, primarily being used as a marketing/PR maneuver. Rarely do patients seem to be consulted about what’s important to them (being able to get through on the phone, anyone?), let alone play a major role in the design of the “home” allegedly centered around them. Insurers use it to demand data about easily-quantifiable processes that they can claim prove higher quality, even though most do not have strong evidence for producing better outcomes – the data-centered medical home. The AAFP uses it to try to improve payment for primary care services (not necessarily a bad thing, at least in comparison to reimbursement for procedural specialties – read the NY Times article last Sun. focusing on Dermatology) and to fight a turf war (the “physician-led PCMH”), which I think alienates potential allies and gains little. The PCMH is patient-centered about as much as Meaningful Use is meaningful.
Yes, exactly. And on the front lines the experience is frustrating especially when we are to espouse the marketing ploy or when “they” come to do a pep rally.