Be Sure to Look for Symptoms in the Waiting Area

As an integral part of the diagnostic process, medical practitioners have relied on visual cues throughout history. Even today, the amount of information that can be gathered through technologically-unaided observation is astounding. As it turns out, the same kind of criteria applied to a primary care waiting room can tell us a great deal about the health of a physician practice in general and the condition of the exam room in particular.

For example, the most basic observation can reveal that waiting rooms are often full of disgruntled people, some of whom have taken to posting videos documenting long waits – which takes negative word-of-mouth to a whole new level. It gets even worse as we occasionally hear of patients who bill their physicians for loss of productive time. While those kind of extreme measures remain rare, the fact is that wait times perceived as being overly long correlate with everything from patient satisfaction and medical compliance to return show rate and overall attitude toward clinicians and staff.

But while the waiting area manifests the symptoms, the problem often lies in the exam room, the very place that patients are anxiously waiting to enter.

Behind those closed doors you’ll still find doctors looking at a computer screen instead of the patient, creating a scenario that neither party considers to be satisfactory. And because the practitioners may be slowed down by the quirks or intricacies of the particular EMR platform, more critical minutes are spent accomplishing less for the people in the exam room – while those in the waiting room … wait.

The typical doctor-centric exam room process isn’t doing the physician any good, either, resulting as it often does in longer days, more work taken home and financial liabilities related to reduced capacity.

The good news is that a “healthier” exam room and, subsequently, an improved waiting room experience can be achieved with some restructuring of the exam room process. And it starts with a specially-trained assistant, generally an RN or protocol-backed MA taking over the data entry portion for the current episode of care while also serving as an information resource for preventive care.

There are a lot of reasons why waiting rooms back up, ranging from the complexity of care and multiple health issues to patients running late, but we’re kidding ourselves if we don’t recognize that wait times are an important issue that will only get worse as coverage continues to expand.

And we’re doing our patients — and ourselves — a disservice if we don’t look for solutions in the exam room.

Making the Right Changes on the Front Line of Medicine

In a comprehensive analysis published recently in the Archives of Internal Medicine, more than 7,000 physicians were surveyed on their quality of life and job satisfaction.  Almost half of them reported at least one symptom of burnout and the overall rate was considerably higher than other U.S. workers even after adjusting for a range of appropriate variables.

The doctors described their symptoms with words like “overwhelmed”, “exhausted”, “detached” and “frustrated”.  Drilling a little deeper into the analysis many reported spending a significant amount of time dealing with administrative tasks and EMR-related documentation, all at the expense of direct interaction with patients.

Not surprising for those of us who have practiced or are currently practicing primary care medicine, the highest rates of burnout occurred at what the study called “the front line” of health care, a category that includes family medicine and internal medicine.

The reasons behind these results are related closely to the larger picture of practicing medicine in today’s struggling and transitioning healthcare environment. As in most complex situations the challenges are far easier to articulate than the means to address them.  But one thing stands out clearly. If the problem is on the front line then at the very least, we have a place to start. For most of us, that front line is the exam room and the broken processes occurring in it.

Reducing Physician Burnout

There are a number of practice initiatives that can help reduce the risk of physician burnout. Few if any have the potential to work as timely or effectively as the team care approach. Having a trained and protocol-directed team care assistant in the exam room, an RN or an MA, to intake preliminary patient information and interface with the EMR frees up physicians to maintain eye-to-eye instead of eye-to-screen contact.  This important capability, despite its decidedly low-tech status, strengthens the personal connection to patients which remains one of the most effective quality-generating factors in medicine

Re-structuring the exam room experience through care coordination holds the potential to positively impact physician and staff satisfaction, patient satisfaction and overall quality of care. At the same time it can improve the financial picture for the practice and readily amortize the cost of any additional staff.

Simply put, the result of this effective counter to physician burnout is healthier doctors, healthier patients and a healthier overall environment in which to practice medicine with increased joy and a greater sense of accomplishment.

Recently I had the honor of appearing on CBN TV and the 700 Club with healthcare reporter Caitlin Burke in her segment Your Doctor Could Be a Total Stranger Soon. Among the many topics we discussed was the challenge of EMR’s, and how physicians list the electronic medical record as one of the key culprits to the accelerating primary care crisis. She’s right. We all know the EMR is essential, but if you do not use it right, it can be a sharp two-edged sword that can destroy your practice. I have been there. I was spending more time looking at the computer than my patients. I dropped from 35 patients a day to 20 patients a day and dozens of my patients could not get in to see me when they needed me. I was losing $80,000 a year, everyone was unhappy with the chaos – my staff, the patients and my family that hardly knew me. I knew the problem was in the exam room. That’s where the bottleneck forms. So for me, I was so frustrated I knew I had to innovate – or retire. So I took myself off of the computer and brought my nurses into the exam room with me. I trained my nurses to do everything I used to do with the patient’s preliminary medical data, and ask all the right questions for both this episode of care and the prevention questions so important to older people. This began to change things immediately. I was able to see more patients, seeing all of the urgent call-ins every day. We increased our available appointments to 35 a day, completely turning around the finances of the practice. Our nurses loved it, and the quality went straight up. And most importantly, I got my life back.

You never see a judge leave the bench and do the stenography for a trial. You never see a surgeon come in the OR without his scrub nurses. And you should never see a highly trained primary care doctor spending more time looking at a computer screen than the patient.

Insistent job pressures cause two-thirds of physicians to experience burnout at some point during their career. As a result, more errors are made and a sense of empathy for patients is lost. In part, this is what’s causing physicians to leave clinical practice all together.

Mindfulness is one of the only known and proven remedies for physician burnout, but it’s not a cure all either. Mindfulness is the ability to be fully present and attentive in the moment; it’s an awareness.

According to a study, patients tended to be more open and satisfied when their physician was focused on their needs and not obviously distracted. Furthermore, mindful physicians were typically more upbeat and concentrated during patient interactions, while less mindful physicians frequently missed opportunities to be empathetic and failed to pay attention.

Danni Alcorn, a Health Writer for Emmi Solutions recently blogged about a personal doctor visit. To give you a little bit of background, Danni graduated from Northwestern where she double majored in pre-med. She considers herself health-literate.

On this particular morning, she writes about how she had been very sick for several days, sleep deprived and delirious. The physician entered the exam room where she was waiting and spouted off several questions to familiarize themselves. She learned that Danni was a recent pre-med graduate and that’s when the visit made a turn for the worse.

“As a patient, I needed to hear my treatment plan explained slowly in simple language. I needed a printout to take with me to remind me of her instructions hours or even days after I left her office. And I needed someone to check with me to make sure I’d actually understood the instructions I’d been given.” Danni writes.

Danni’s experience further proves that some physicians are determined to stay on their focused path of seeing patients, documenting what medical data needs to be documented and moving onto the next patient day in and day out.

Did you know that 80% of what patients hear, they forget by the time they reach the parking lot?

The issue is not whether physicians want to be mindful, it’s that they are distracted by the many patients they have previously seen, wondering if the recommendations they made were best, remembering they have forgotten to call in an order or call back a patient. Their minds are always working and it prevents them from being mentally present.

Back in 2002, when I was practicing medicine at Hilton Family Practice in Newport News, VA, I found myself experiencing similar situations. It was all I could do to get through the day, then to realize that it all had to be repeated when I woke up the next morning was depressing.

About a year later, with the help of two of my nurses, I decided to change the workflow of my office, primarily the patient visit. I elevated the responsibilities of my nurses to include gathering data, scribing patient visits on the EMR, and educating patients. This ultimately relieved me of responsibilities that did not necessarily require my expertise as a physician and allowed me to devote my full attention on each and every one of my patients.

I quickly experienced a more efficient exam room dynamic, increased quality of care, documentation was complete and competent and financial performance sky rocketed. Moreover, I started enjoying practicing medicine again and my staff was experiencing the same professional satisfaction.

Having extra staff to help with documentation enables physicians to be more mindful because its takes many of the tedious responsibilities off of their back and out of their mind.

Dr. Mary Catherine Beach, lead author of the study and an associate professor of medicine at Johns Hopkins University said, mindfulness “…allows doctors to help patients by listening more, talking less, and seeing what the patient needs.”

Adopting a sense of awareness while interacting with patients benefits both the doctor and the patient and is essential in nurturing this doctor-patient relationship. The Family Team Care model offers a way to improve physician’s ability to be “mindful” of their patients and reduce burnout.

Overdiagnosis and overtreatment have become a rising concern for patients, as new research is being released. While it is hard to determine the extent to which overdiagnosis and overtreatment may cause harm, it also varies from one health screening test to another. It’s alarming for anyone who undergoes testing to receive news that they “might have cancer, but it’s hard to tell”; or they “in fact have cancer, but it’s so small and slow-growing it would never cause a problem”. In most cases like these, patients have biopsies, surgeries, radiation and take drugs to protect their quality of life.

Unfortunately, patients are ill-informed and possibly physicians too.

Many of the next-step procedures patients go through are not 100% effective. They understand the benefits that may result from these procedures, but are uniformed about the potential side effects.

Mammograms and PSA tests have proven to be extremely beneficial in detecting cancer early enough to save lives, but there is also 10 or more cases of overdiagnoses for every life saved according to a study conducted in Berlin.

The same study showed that many patients have an emotional attachment to their regular health screenings. It’s hard for many to comprehend that a routine screening they have always received may not be necessary and/or harmful.

Don’t get me wrong, regular health screenings save lives and I too believe in them. The point I am trying to get across the need for physicians to better educate their patients on the benefits, as well as the risks.

Furthermore, the presence of a primary care physician’s expertise and knowledge about the patient’s medical history is crucial to determining if the “next steps” are appropriate.

There have been many breast cancer awareness stories, both fortunate and unfortunate, buzzing around this month.

One story tells of a woman who noticed redness under her right breast and later found a tumor. She immediately scheduled an appointment with her primary care physician, who confirmed her findings.

Several days later she met with a surgeon, recommended by her physician. After undergoing a bilateral mastectomy, oophorectomy, chemotherapy, more surgery and radiation, she is cancer-free. She states, “I am a survivor because I had competent specialists who treated my cancer along with a primary care physician who was, and still is, an advocate for me…”

This is the final installment in a series on the nine forces I identified in The Familiar Physician: Saving Your Doctor in the Era of Obamacare as being part of the perfect storm threatening primary care medicine. While the EMR fits into that category, I want to be clear in conveying that I am an early adopter and strong advocate of the electronic medical record and recognize its potential to improve the quality, safety and efficiency of care while adding to patient empowerment. I would add that while the data entry part of the process can feel a little clunky at first for anyone who grew up on paper charts, you can’t beat the ease of retrieval and sharing.

Having said that, I should mention that if you’re a physician who hasn’t already made the transition, it will take longer to implement and cost more than you imagined or planned. And the learning curve may be steeper than you think, especially when it comes to customizing the EMR for a specific medical practice.

Putting it into very simple terms, what the EMR represents for a large portion of primary care physicians, especially those not employed by a health care organization, is both a blessing and a curse.

Of course physicians transitioning from paper offices to electronic ones who meet the “meaningful use” criteria can take advantage of the incentive programs established through the Recovery Act/HITECH Act of 2009. But the costs you may not consider involve a substantial disruption of workflow in areas like billing and accounts receivable, basic patient documentation, scheduling, lab results and more. Plus a large chunk of time given up for initial as well as ongoing training.

Considering that many PCPs are already harried and working close to the margin, the time demands of adopting the EMR can feel crushing, especially since you’re not just learning a new way of documentation but also a new approach to patient care.

The challenges are exacerbated for independent practitioners, still the nation’s largest percentage of primary care physicians – and least able to bear the loss of productivity – because they are balancing the cost of an effective EMR system with reimbursement cutbacks. This one issue, more than any other single factor, has been the prime motivator for pushing otherwise unwilling doctors into large medical groups.

The truth is, no one doubts that the EMR is a storm pattern with quite a bit of blue sky and fair weather behind it. Nonetheless, for physician practices in the midst of converting, it initially hits like a Force 12 on the Beaufort scale.

The seventh in a series of metaphoric bad weather descending on primary care medicine involves the ever-present threat of malpractice. In The Familiar Physician: Saving Your Doctor in the Era of Obamacare, I referenced a study conducted by the Physicians Foundation entitled A Survey of America’s Physicians: Practice Patterns and Perspectives. This extensive project identified “liability and defensive medicine” as the least satisfying part of medical practice. As the survey drilled down a bit words like “resentful” and “angry” often come into play – not only at the threat of being sued, but also the corresponding need to practice expensive defensive medicine, not in order to validate a diagnosis, but to reduce the risk of a lawsuit.

While there is considerable variation involving malpractice on a state-by-state basis, the national picture reveals that the total number of lawsuits is on a downward trajectory. This direction is balanced, however, by the fact that the actual amounts per damage award are growing. At the same time, insurance premiums are rising again after a recent plateau while the number of firms offering coverage decreases.

The problem is also widely distributed. A 2010 American Medical Association Physician Practice Information survey reveals that nearly 40% of primary care physicians have been sued in their careers, as have 34% of general internists. As you might expect, the numbers get even higher for surgeons.

In addition to the costs of malpractice insurance, the long hours involved in dealing with lawsuits can represent a considerable drain on time. In many cases, claims, even those not leading to lawsuits, can take years to resolve.

According to the Physician Insurers Association of America (PIAA), a group of doctor-owned or operated liability carriers, the highest percentage of malpractice suits, more than one third, are related to errors in diagnosis.

These claims are often complicated by insufficient documentation and poor communication between physician and patient, both of which may be attributable to the inefficient business model and structure currently in place in many medical offices in America.

Within this context, the one thing that does look fairly certain based on both research and a very large amount of anecdotal evidence is that a causal relationship exists between medical malpractice filings and the erosion of the interpersonal relationship between doctor and patient. The slow but steady disappearance of The Familiar Physician is creating a lack of trust, a weakening of the traditional bond between provider and consumer that even needed tort reform and improved risk management won’t improve.