The Business of Medicine -vlog link
In youth I used to dream of being an athlete. Growing up I was fast, I would carry the 8th grade guys on my back when we played “kill the man with the ball”. (Think of me walking one step at a time with a dog pile of guys trying to weigh me down to drop the ball) I was amused that my legs could carry a lot of weight but just went with it hoping no one would figure out to grab my legs. In youth I used to dream of a lot of things so why is it we stop dreaming? You only hear of the rare human like Steve Jobs or Elon Musk or even earlier scientists like Einstein or inventors like Edison coming up with a concept that “sticks” for the rest of time. I submit to you its all based in day dreaming.
Currently best visions come at 430-500am when ideas overflow (if I allow them). I wake do my 478 breath exercise, go downstairs sit overlooking my backyard while waiting for kettle to boil then sit more while brewing my gyokuro tea anticipating the first taste all the while imbibing nature therapy. Ideas flow like a fire hose opened full force.
This wasn’t so about 18 months ago; I would wake anticipating the tasks of the day and open my computer, log into the electronic medical records and start preloading patient data while downing a pot of coffee. I remember my wife coming down one morning asking me something and I remember snapping at her as she was interrupting my flow and I only had 40 more minutes to do these charts as the ones from the day before were not complete and as soon as I entered the gauntlet of the office every second would be accounted for.
This sounds blown out of proportion BUT its true. One would think its should be easy to type, in prose style as the patient is speaking; come up with a diagnosis and a treatment plan all on the fly BUT it is not! What overshadows the time spent with patient is the arduous “CI’s” (clinical integration?) that is required for all doctor offices employed by hospital to fulfill in order to assure you get all the requirements for clinic site to get bonus. The “CI’s” go into asking about recent vaccines, Pap smears, colonoscopy, prescription meds, blood pressure... ALL not what the patient is presenting for the day of BUT are necessary as a “by the way” while you are here can we get our bonus. AND those questions and key strokes take seconds to minutes in an office visit to accomplish. (If your doctor is running 15 minutes behind and In addition now has to go through those CI questions; then enter data by checking boxes-this will take an extra 5 minutes (IT JUST FURTHER DELAYS AN ALREADY DELAYED DAY!!!) And that is just second patient of a 25+ patient day. 15 minutes behind x 25 patients = extra 375 minutes end of day (6 hours delayed to go home and eat dinner). 20 minutes behind x 25 patients = extra 500 minutes (8.3 hours delayed to go home). Now for the rare doctor running on time, adding an extra 5 minutes per patient for average 25 patients = extra 125 minutes (2 hours delayed to go home). THIS IS ONLY PATIENT CHARTING AND DOES NOT INCLUDE THE PATIENT THAT IS CALLING IN WITH A NEW PROBLEM, OR TO FIND OUT ABOUT RESULTS OR CALLING FOR REFILL OF MEDS OR CALLING FOR A 4 PAGE DISABILITY FORM TO BE FILLED OUT (all these things mentioned are hourly occurrences!!!)
So if I would be a slave to the task-master of the day (the electronic medical record) then even adding a few extra key strokes adds up. GOD FORBID IF A PATIENT HAD AN AFTER THOUGHT QUESTION AND I HAD TO LEAVE THE NEXT PATIENT ROOM TO REENTER THE ONE I ALREADY LEFT. No wonder I hear some docs are answering questions while walking out the door or literally doctor “spent 5 minutes in the room” is a common occurrence. My wife would wonder why I wouldn’t check my text messages and its because I just wanted to run out the back door after I finished the most crucial work (leaving some unfinished questions to be answered on next days schedule) and get to the sanctuary of my home. This gauntlet would occur 5 days a week and infect my “time to day dream”. In fact it induced a stress response that would wake me up at 420 for fear that I didn’t preload the charts in time to be out the door in the am to drive my son to school. No wonder heart attacks occur across the world mostly on Monday!
Turning on the stress response can be useful for getting out of life threatening situations. It’s not like you have to manifest full fight or flight and carry a machete In the clinic but the rapidity of the tasks demands you think fast and use algorithms to survive the day. Here is the rub, average patient doesn’t give a shit what the doctor has to go through, the patient is suffering and just wants it to stop. Patient demands attention from the provider and demands focused problem solving to come up with answers and a plan of action. The average corporate paid doctor WILL provide that BUT it will be in algorithm form. To survive the day, every patient’s verbalized symptoms will be keyword focused. Front desk and clinic area will be focused on listening for keywords of symptoms IN ORDER to lump patient into a treatment algorithm and produce a rapid solution. The more rapid the solution, the more on time clinic runs, the MORE CI gets accounted for and the faster staff leaves to get home and spend time with family.
Unfortunately, every person notes a common symptom but the rest of what they are feeling may not be understood by a layman thus its not divulged to staff when making the appointment or at check-in on the visit day. Typically the doctor is supposed to question further (“outside the box questioning”) to make sure the symptoms are not from a deeper root cause. BUT WHO HAS TIME!!?
Patient: “...but doc its my 4th bladder infection this year”. Doctor: “...its ok as women are allowed to have UTI’s frequently...any other final questions?”
When doc is thinking in stress response 5 days a week, it doesn’t allow for “dream time”. This time is when you think “outside the box” to become inventive. More importantly become inquisitive. When patient is coming in over and over again with bladder infection symptoms ...is there something else lurking in the body that is starting to express itself? Naaa... if it was important it’ll declare itself and we can get the specialist to cut it out, burning it out or melt it out! Or more appropriately if it keeps coming back, it probably needs a prescription thrown to keep it from recurring again.
Doesn’t seem like a fulfilling career, or a great work schedule BUT nice paycheck!!! (Average primary care salary in Illinois is $181,000 annually.) BUT that’s the guaranteed base salary as you are “starting out” working as an employee. As you get established in 3 years your paycheck gets smaller and smaller as a “reverse incentive” to make you work faster and get back to the huge paycheck like the “protected” first year of working. The only way to stream line everything mentioned above in the daily schedule is to treat the whole week as an algorithm. Assume most patients will be sick from infection or sick from over eating or stressed out from life. Preload all the days of the week with the typical algorithm answer of antibiotic, diabetes pill, or mood altering drug. In fact, may as well just preload the entire month and year for figuring most patients you see will fit into the usual categories so anyone that calls with the smallest of symptoms or the beginning of a disease on recent blood test results should be placed on the most rapid medicine for the general population.
When docs don’t have time to think in abstract and go into personalized-time-consuming-problem-solving, all patients are treated like cattle and branded to end up same way. THIS IS CALLED THE ECOLOGICAL FALLACY. It is assumed the data from the individual is treated as the research outcome data coming from a larger group. Does this sound familiar? Patient Lives Matter!!! Medical community should not assume all patients coming in with symptoms will be successfully treated based on the data of the general population. If I was to give metformin to anyone overweight with an elevated glucose and assume they are not going to lose weight or change lifestyle, you pigeon hole those patients that would otherwise have committed to change and reversed their disease. BUT WHO HAS TIME TO DIVE INTO PERSONAL INVESTIGATION TO FIGURE OUT WHO THE OWNER OF THE SYMPTOMS IS AND WHAT IS THE ROOT CAUSE OF ALL THIS!?!
When I do lifestyle coaching online, I can sometimes spend 1.5-2 hours trying to figure who this person is...the proverbial meet the client where they stand. However ask the hospital you work for if you can spend 1.5-2.0 hours and just see a fraction of patients daily as compared to the ‘average” and you will be laughed away pointing out you are “not keeping up”. There is a saying in social work to meet the client where they are / instead of being prescriptive, try to improvise to co create a plan of action PERSONALIZED to the individual. Going right back to where I started this blog, improvising is a learned talent... or should I say its a natural talent from youth displayed in day dreaming. It’s a natural talent that in adulthood that is “unlearned” to allow algorithm medicine and the ecological fallacy to anchor.
- Doctors: Don’t be afraid to Dream BIG!!!
