26 hours in a day: the impossible math of providing quality care [PODCAST]

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“Until I have dedicated time during the week to tend to administrative tasks, I must work 12 to 14 hours most days just to stay afloat. If I fail to work at least 12 hours per day, my in-basket accumulates, invading weekends, vacation days, and future workdays. As my and my nurse practitioner’s schedules get fuller, the responsibilities increase without respite in sight. It is not sustainable.”

Today’s guest is an anonymous family physician.

She shares her story and discusses her KevinMD article, “26 hours in a day: the impossible math and timing of providing quality care.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show, we have an anonymous family physician. Her KevinMD article is titled “26 hours in a day: the impossible math and timing of providing quality care.” Thank you so much for joining me today.

Guest: Thank you for inviting me.

Kevin Pho: So we’ll get into the article in a little bit, but first off, just briefly share your story and journey to where you are today.

Guest: Sure. So I am originally from [state removed] and grew up in the metro [city removed] area. My mom was a nurse, and otherwise I didn’t really have anybody that I knew in medicine, but I shadowed a general surgeon who really inspired me to get into the medical field. I just love that he could make such a difference in people’s lives, and I wanted to do the same thing. So I ended up going that same route, and instead of doing surgery, I really found myself attracted to family medicine, because I felt like that was a good way to really get to know my patients well and do a little bit of everything.

Kevin Pho: And has family medicine been what you expected?

Guest: Yes and no. Certainly it’s been very rewarding in some ways, but I don’t think that I realized in my training just how challenging it was going to be as well, as far as all the systemic issues, all the things that kind of work against you, from insurance companies and prior authorizations, and just how hard it is to do comprehensive care in such a short period of time.

Kevin Pho: Now, for those who aren’t familiar with the primary care setting here in the United States, and I’m a primary care doctor myself, just paint us a picture. Give us an example of some of these obstacles and some of this bureaucracy. How does that interfere with optimal patient care?

Guest: Oh boy. Well, I can give you an example from today, even. I saw a patient for a hospital follow-up, but this patient was seen at a different hospital than the one I’m affiliated with. We didn’t have records, and she didn’t know all that she was diagnosed with, and she had a lot of concerns and needed things refilled and referrals. And because that hospital didn’t want to readily share that information with us, I was really operating in the dark. And then as I’m putting medication in, I’m getting alerts that her insurance may not cover it. It’s just like at every step of the way, there are extra processes that interfere with me getting the information I need and the patient getting the care that they need.

Kevin Pho: All right, now let’s talk about your KevinMD article, titled “26 hours in a day: the impossible math and timing of providing quality care.” So this is framed as a letter. Now tell me how this letter came about.

Guest: Yeah, so I was trying to figure out a way to communicate with the administrators at my hospital system about exactly what I do. I am in a rural family medicine clinic. It just opened a couple of years ago, and I think that in some ways it’s singular compared to some of the other clinics around here, in that it is new and I am here solo. And I get a lot of pushback: “Well, why don’t you see even more patients?” or “Why do you routinely spend 45 minutes or an hour with a patient? How can you do that?” And I really wanted to explain just what a few minutes in my life are like here, and how there’s just so much that I’m balancing, and some patients who just really, truly do need a lot of time.

Kevin Pho: So just to give some context, you are a solo private practice practitioner? Is that correct?

Guest: So I am a solo practitioner in a family medicine clinic that is hospital-run, and I do have a nurse practitioner here as well.

Kevin Pho: And the administrators, do they have a sense of your workflow, or of what you are up against every day?

Guest: I don’t think so. That’s why I wrote this email.

Kevin Pho: All right. So tell us, what did you write?

Guest: Well, I had a particularly difficult day, in which I had one patient who was confiding in me that he was depressed, and then his wife pulled me aside, and she was actually more worried about dementia. And meanwhile, I had staff coming at me like, “OK, well, the EKG machine’s not working right,” or “Hey, there’s a patient in the lobby having a seizure.” And then there were just so many people who were walking in, and it was a lot happening all at once. I wanted to communicate that this is actually not atypical; this is kind of how things go here. There are some downtimes. It’s not always that crazy, but every day is full, and there’s a lot of information coming at me, and at my nurse practitioner as well. We just have a lot of stuff to process. It’s difficult to do that and also meet all those quality metrics and also get all the coding done. And I wanted to express why sometimes that’s difficult for us.

Kevin Pho: How many patients would you typically see in a day, and how long are your appointments booked for?

Guest: So it varies. We have a fairly high no-show rate, just because of the area that we’re in, or people don’t have good transportation, but we also take walk-ins. So the day is a bit unpredictable because of that. I would say that between the two of us, we usually see close to 30 patients, divided about evenly, but that can vary. I mean, sometimes it’s in the 20s, sometimes it’s in the 40s. The appointment slots are generally 20 minutes long. New patients and procedures are 40, but realistically, all of them take almost double what they’re actually booked for.

Kevin Pho: And in between, you have to deal with patient messages, refills, and calls from specialists and the hospital.

Guest: All of the above, yes. And then questions from staff, and questions from my nurse practitioner, who sometimes is not sure of the next thing to order, or physicians calling, and prior authorizations where my nurse isn’t really sure what information needs to be put on there, all kinds of things. It’s a constant flow. It never really stops.

Kevin Pho: And on a typical day, what time would you enter the clinic, and what time would you leave?

Guest: So our first patient is at 8 o’clock. I like to be early. It doesn’t always happen, but I’m usually in the clinic at 7-something or 8, and I don’t leave the clinic till 7 or 8 at night. So I’m here pretty late, because even though our last patients are usually done at about 4:30, there’s just so much administrative stuff to do afterward.

Kevin Pho: Like what? What’s an example of some administrative stuff that you would do after you see the last patient?

Guest: So patients send MyChart messages, and I don’t always have a nurse here, or even when I do, sometimes they’re not sure how to answer those questions. So a lot of those get sent over: refill requests, results, some of which are fairly urgent, that I can’t just put off to another day. So I have to figure out, “OK, what am I going to do with this? Let me contact the patient. Let me order something and follow up.” A lot of paperwork too, so a bunch of forms and things to sign that come in. And then, of course, there’s all the charting: going back through all the people that I saw that day, trying to figure out all the billing and coding, and making sure that I have the follow-up labs ordered and that all the i’s are dotted and t’s crossed.

Kevin Pho: So I guess against that backdrop, you would be in clinic for pretty much 12 hours, seeing patients all day. After the last patient, there’ll be a couple of hours of administrative work, answering MyChart messages, finishing charting. And in that context, the administrators would still want you to see more patients. Is that correct?

Guest: Oh, yes, absolutely. And then the other thing is that I am very detail-oriented, and I want to make sure I’m thorough with my patients. And so I have a tendency to get behind on documenting things. And so if I’m even a day behind, then the next day is even more punishment, because then I have all that day’s work, but also the previous day’s. And that’s where the impossible math comes in. Like, “Oh, shoot,” if anything happened the previous day that was out of the ordinary, which, I mean, happens a lot, if there’s a particularly difficult patient that I spend two hours coordinating care for, then I’m now behind, and I have to make that time up somewhere. So do I sleep less, or skip a meal? Where does that come from?

Kevin Pho: How would they communicate that to you? Would they just come out and say, “You have to see more patients”? Would the pressure be more insidious? How would they communicate to you that they want more productivity?

Guest: They would say, “Well, others have figured it out, so you can too.”

Kevin Pho: They literally said, “Others have figured it out. Why can’t you do it too?”

Guest: Yes.

Kevin Pho: And how did that make you feel?

Guest: Very small. Yeah, I don’t know. I think it would be a violation of my conscience to not give people the care that I believe they deserve, and to rush through things, and I have witnessed other physicians who do that. And I can’t say that I’m always perfect, of course. Sometimes I do rush more than I want to. But if I just go through the motions all day, what am I really doing? Is this actually a healing profession, or am I just a technician?

Kevin Pho: What would those other physicians be doing that you wouldn’t be? What would be an example of that?

Guest: Well, I ended up shadowing one physician just to see how they got through their day, and they never sat down. I mean, they would walk into a room and interrupt the patient and say, “OK, I refilled everything. Anything else you need?” And then if the patient even said anything, they didn’t really listen, and they did the exact same exam on everybody, and it didn’t matter what that exam yielded. They just ran in and out. And they did delegate a little better than I think I did. So I learned some things. OK, maybe I could ask my staff to do a little more here and there, and maybe there are more efficient ways to use the system. So it wasn’t entirely a lost cause for me, but it was still like, “This is not how I want to be.”

And I could tell the patients were a little frustrated too, like, “But I was just telling you I was depressed,” and this other physician said, “Yeah, well, aren’t we all?” and walked away. And that was the person who was really being built up as the pinnacle of efficiency, like, “This is someone I need to be like.” And I just can’t do that.

Kevin Pho: You mentioned in the letter that you have your physician group’s highest patient satisfaction scores. Is that correct?

Guest: It is.

Kevin Pho: And did that matter at all to the administrators when you presented this feedback to them?

Guest: Well, I actually never got a response to this. But they did end up calling a meeting with me recently, in which they told me that I bring, quote, “no value” to the hospital system.

Kevin Pho: They literally told you that you brought no value to the hospital system, working the amount of hours that you do and having the group’s highest patient satisfaction scores.

Guest: Correct.

Kevin Pho: How long do you feel like you can keep on doing this?

Guest: Not much longer.

Kevin Pho: Are you looking for a different practice? Are you looking to leave medicine completely?

Guest: You know, I’ve thought about leaving medicine completely, but I mean, I love this. I don’t love all the nonsense, all the administrative stuff, but I love being able to work with my patients and figure out what’s going on, what’s going to be best for them, and it can be extremely satisfying. It’s just that those moments are becoming fewer and farther between. So I’ve really been thinking about doing direct primary care. That seems to be a better fit for me this way. It’s built in that there’s more time with each patient, and there aren’t the insurance companies that always have to be satisfied with pre-certifications and prior authorizations and all that. And I think that would be a model that I would succeed in a little better than this one.

Kevin Pho: Do you feel that this is just specific to the hospital group that you’re in, and these particular administrators are particularly toxic? Or do you think that this is the norm for the area that you’re practicing in?

Guest: I think this is a problem in most places, perhaps not to the degree of where I am. But it seems to be a theme, especially in primary care, that it’s just “do more, see more,” but somehow also do it all better, make sure you don’t make any mistakes. It’s just not a sustainable model. And I understand that if someone doesn’t see enough patients, then unfortunately they’re really not bringing in enough money. That’s how the whole payer system works in this country. It just devalues primary care so much that for me to get credit for all the things I do, I have to click so many modifiers and CPT codes and all this stuff. And even then, a family medicine appointment, compared to any kind of surgery or procedure or even just a specialist consultation, the RVU value is just much lower. So it forces us to work this way.

And then I end up having trouble just finishing everything, because there’s just so much to finish. I kind of shoot myself in the foot in that sense, I guess: I do all the work, but I have trouble showing the credit for it, because the process of showing that credit takes so long.

Kevin Pho: Do you feel that you’re burnt out from your current practice?

Guest: Absolutely.

Kevin Pho: Who do you turn to for support? You mentioned that you practice with a nurse practitioner. What’s your support system like, to share some of these stories with and to commiserate with?

Guest: Yeah, so thankfully, I have found some online forums for that, and some national organizations. Unfortunately, where I am, there are not a whole lot of other physicians. Within the hospital system there are, but I’m geographically removed from them. So I have to really make an effort to connect, and it’s actually been easier to connect with people in the American Medical Women’s Association, for example; that’s one I’m pretty active in. And I’m in the Wilderness Medical Society; that’s another. And I’m a veteran, and so connecting with other veteran physicians, or just veterans in general, has been a huge support.

Kevin Pho: So tell me, what will your next steps be?

Guest: Well, I’m looking for a direct primary care practice that I can join, or another physician who would be willing to open one with me. I’ve been looking for a few months now, and I’m not sure exactly where I’m going to land yet, but I have some promising leads.

Kevin Pho: And if it wasn’t for the administration, if it wasn’t for the bureaucracy, do you enjoy the medicine itself? Do you enjoy the interactions with patients?

Guest: Oh, yes, absolutely, I do. And it’s very rewarding when I help a patient to feel better, to figure out what’s going on. Maybe they don’t get completely cured, but they can get some relief or some answers. There’s just nothing quite like that.

Kevin Pho: We’re talking to an anonymous family physician. Her KevinMD article is titled “26 hours in a day: the impossible math and timing of providing quality care.” Now, I think what you describe is certainly not uncommon among primary care physicians. The burnout rate is approaching 70 percent in the latest studies. Do you have any pieces of advice that you could share with other physicians who may be undergoing the same travails that you describe?

Guest: I think it’s important to reach out to other physicians, to know that you’re not alone, that unfortunately, like you just said, this is a very common experience. And there are ways out of individual situations. So just because it’s bad in one place doesn’t mean it’s necessarily bad everywhere. Yes, there are a lot of practices that are either toxic or where everybody’s just overworked, but I think there are models like direct primary care, or academic institutions, or just other ways of practicing aside from a traditional setting, that are promising.

Kevin Pho: And my final question: What are some of the take-home messages that you want to leave with the KevinMD audience?

Guest: I want to make sure that others know that primary care physicians are suffering, but that we are resilient, and we’re going to figure something out here, hopefully with the support of our colleagues. I know that we’ve always been kind of relegated, I guess, to sort of the bottom of the food chain, like not as important or not as highly valued as some specialties, but we’re the backbone of medicine, and I hope that we will continue to be. So things may get worse before they get better, but we’re important, and we’re not going anywhere.

Kevin Pho: Well, I wish you all the best in finding a better practice situation. Thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

Guest: Thank you.

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