Extra Staff Leads to Mindful Doctors

Extra Staff Encourage Doctors to be More Mindful

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.

The Truth About EHRs

The Truth About EHRs

Simply put, an Emergency Health Record (EHR) is a digital version of a patient’s paper chart. According to HealthIT.gov, it’s a real-time, patient-centered record that make information available instantly and securely to authorized users. Providers typically utilize EHRs to access patient information, document care, e-prescribe, view lab and test results, and enter orders.

IDC Health Insights conducted a study that looked at the current state of ambulatory provider’s use of EHRs. They reported that providers transitioning from paper records to EHRs share similar goals: regulatory compliance, improving the quality of care and qualifying for meaningful use incentives.

While the adoption of EHRs has been widespread, the majority of providers using them are dissatisfied.

Most office-based providers find that their productivity decreases with the implementation of EHRs. Contributing factors include, but are not limited to, inadequate training, staffing and support, poor usability, inappropriate form factors and user interfaces.

Unfortunately providers have faced several stumbling blocks along the way. Productivity has been jeopardized as a result of providers spending an increased amount of time documenting data and thus costing them their availability to see patients. Furthermore, EHRs may seem cumbersome to new users and often act as a barrier to providing quality care to patients.

This Fall, RAND Corporation published a report that presented the possible culprit behind provider’s stress. Typically providers experience job satisfaction when they believe they are providing high-quality healthcare. They begin to feel unhappy and stressed when circumstances, like adapting to a new way of providing care through EHRs, gets in the way.

The same study brought to light that provider’s feel EHRs are a distraction from face-to-face interactions with their patients and requires provider’s to spend too much time performing clerical work; it also degrades the accuracy of medical notes by encouraging the use of general templates.

While it is not an easy road to pursue, providers recognize the value of EHRs. Those reaping the benefits of EHRs report that there has been a reduction in the number of charts lost or missing, the ability to access medical charts and work remotely, as well as incentive payments.

Judy Hanover, Research Director at IDC Health Insights states “Success and productivity with EHR will become even more important as EHR installations become the building blocks for care management, patient engagement and patient-centered medical home operations under accountable care.”

Why Do We Have Regular Health Screenings?

Why Do We Have Regular Health Screenings?

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…”

Credit Cards & Doctor-Patient Relationships

The Doctor-Patient Relationship Under Attack…by Credit Cards

Financing companies are offering doctor’s offices financial incentives for recommending financing options to patients who may not be able to afford products or procedures.

This is not a new idea; the ability for patients to open a credit card or receive a loan for medical procedures was first seen for cosmetic surgeries and elective surgeries. Unfortunately many older American’s find themselves with their backs against the wall because their care, even the most basic kind, are not being covered by Medicare or private insurance.

The New York Times recently wrote about an elderly woman who went to see her dentist for a problem and later found out she needed a partial denture. She was floored when she received the bill – $5,700.

Empathizing with her, the dentist office offered her a solution – a line of credit.

At first thought, it doesn’t necessarily sound like a bad idea. However, patients and doctor’s offices are being deceived.

iCare Financial of Atlanta, a financing company that offers an assortment of financing plans through doctor’s offices have experienced a 320% increase in enrollment over the past three years. They appeal to providers by showing patients vanishing from their waiting rooms because of the inability to pay for procedures.

The efforts that physicians and other medical personnel put forth to build meaningful relationships with their patients are diminished by offering these forms of payment. Interest rates are typically over 25% and increase automatically, often times the rates are retroactive, meaning they are applied to the patients’ original balances, rather than the amount they still owe and there are additional fees if payments are made late.

While medical credit cards and medical loans may be the only option for some patients, it’s not always the best option. Bear in mind that you are the representative for financing companies; whenever there is a problem, patients are more than likely going to blame you.

A chiropractor in Alaska once offered medical cards at his practice, but quickly learned that one missed payment could ruin a patient’s finances and life. When talking with other physicians, he asks them to consider if this is something they would recommend to their friends and family. Usually the answer is no, he says.

What to Know About Prescription Medication

What Everybody Ought to Know About Prescription Medications

The price of medicine follows the same trend as our country’s delivery model of healthcare – broken and health insurance will pick up a large chunk of the bill.

Unfortunately for many, the prices of drugs are too high, another indication of our healthcare system’s crisis. It does not matter how many good drugs are available, if they’re unaffordable, it is of no help to patients.

The ability to afford prescription medications in the United States requires the best insurance, disposable income, and extra time to research how to save money.

Patients are known to scale back on their prescribed dosages to save money. One out of two patients don’t take their medications exactly as prescribed, which leads to additional office visits and further treatment. In the end, untreated diseases cost the culture, as well as the individual much more than the medication does itself.

Did you know? Drugs account for more than 10 percent of our country’s $2.7 trillion annual health bill, even though the average American takes fewer prescription medicines than people in other countries. The price of a typical steroid inhaler in the United States may cost $175, while the same inhaler retails for $20 in other countries.

Generics were introduced as a more affordable option to brand-name drugs. However, the price of generics has increased approximately 5.3 percent and often times are unavailable.

The United States allows pharmaceutical companies and generic drug makers to compete for the price of drugs which leads to the high prices we are forced to pay.

While prescription drug spending has declined due to the recession, it is expected to increase sharply as millions of Americans are becoming insured under the Affordable Care Act.

Building Better Healthcare Systems

How To Build Healthcare Systems for the Future

What mainstream business or product has stayed exactly the same since its creation?

Times change, people change, our needs as a culture change.

Change is undoubtedly hard, especially for the field of medicine which has changed very little over the past several decades.

There is a dire need for disruptive innovation in primary care as well as a reduction in healthcare costs. Patient-centered medical homes (PCMH) have the potential to accomplish these needs and more.

The hope of this new approach is to redirect patients from emergency rooms and hospitals to primary care offices, keep patients healthier and make primary care an attractive field for medical students to pursue.

Within a PCMH, a primary care physician leads his team of professionals who take more responsibility in providing care for a panel of patients. No longer do physicians solely handle patients; nurses are much more involved in the process of providing care, maintaining wellness, and patient education.

A cultural shift is most evident when physicians have to retrain themselves how to function within their office setting; they absolutely must learn to delegate certain aspects of care for their patients to nurses and medical assistants to meet the coming demand and improve outcomes.

Transforming a practice into a medical home does not have a one-size fits all price tag. For some it may include hiring new staff, temporary loss of productivity, purchasing an EHR system, etc.

Further upfront costs may include scheduling more office visits, improving patient adherence to prescription regimens and ordering more tests to ensure chronic conditions are maintained. However, all of this is done to ensure that those patients who may be at risk for a heart attack or some other life-threatening condition is closely monitored and treated, thus their care will be cheaper by detecting such conditions early. Protecting wellness and maintaining health are much cheaper than treating disease.

As many skeptics are quick to point out, it is difficult to measure PCMH’s cost-effectiveness. Though it may not generate short-term savings, over and over you hear stories about physicians falling in love with medicine again, greater adherence to prescription regimens, increased use of generic drugs, fewer hospital admissions, and less use of skilled-nursing facilities. It is inevitable as patients see their physician, costs will come down and health will improve.

Utilizing a patient-centered medical home aligns primary care physicians, specialists and hospitals to work together to optimize treatment rather than be in competition with one another.

Undeniably challenges lie ahead, but patient-centered medical homes are the way to building healthcare systems for the future.

What can Massachusetts Tell Us?

Based on the events and actions that took place in eastern Massachusetts in the colonial period and during our nation’s fight for independence, Boston has appropriately been called the Cradle of Liberty. As a result of its pioneering efforts in health care legislation, there’s a strong argument for calling the entire state the Cradle of Health Reform. The legislation that Massachusetts passed seven years ago, popularly called Romneycare by many of the state’s residents, has served the population effectively by most accounts.

In researching The Familiar Physician: Saving Your Doctor in the Era of Obamacare, I came across voluminous literature that compared and contrasted the state model with the nationally-directed Affordable Care Act, now widely known as Obamacare.  Jonathan Gruber, a leading health economist who consulted on both pieces of legislation said that they are markedly similar on most issues where they can be fairly compared.

At the same time, there are some noteworthy distinctions.  When Massachusetts adopted its health care law a large percentage of its residents already had health insurance. So part of the legislation’s objective was to cover nearly everyone by plugging as many holes as possible in the existing system, a task that is less daunting, by quite a few levels of magnitude, than the federal initiative. In addition, the tough issue of pre-existing condition exclusions had already been addressed at the time of the state reform efforts.  And of course, like any other individual state, Massachusetts is not a microcosm of America.

My intent is not to make a judgment on the relative merits of the state and the federal legislation, but rather to look at one potential correlation that may give us an insight into what to expect when the insured patient pool is expanded across the country.

According to the Huffington Post writer Steve LeBlanc, just half of primary care doctors in Boston, a city with 14 teaching hospitals, were taking new patients five years after the law went into effect, and average wait times for new patients seeking appointments grew considerably according to a Massachusetts Medical Society survey.

Alan H. Goroll, M.D., a professor of medicine at HarvardMedicalSchool and a practicing PCP, says this aspect of the Massachusetts health care initiative is an example of what can go wrong if the primary care system isn’t fixed simultaneously with the start of expanded coverage.

Specific provisions of the ACA will be phased in all the way through 2020, so it’s difficult at this point to speculate as to where the correlations lie. But one thing we can count on is this: if our goal as a nation is to provide medical coverage for as many people as possible, we have to make sure that a sufficient base of primary care medicine, as part of a larger, integrated system, is ready to care for those people.

EMR and EHR Fatigue

The Nine Forces Converging on Primary Care: #9 EMR Fatigue

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.

Physicians Heading Towards Retirement

The Nine Forces Converging On Primary Care: #8 Heading Toward The Retirement Exit

In the past seven blogs I’ve been looking at the various forces that have created a perfect storm lined up against primary care medicine. In this eighth installment in a series of nine it’s time to face the reality that medicine is currently experiencing a significant exodus of older physicians. It’s been estimated that one out of three practicing physicians in the United States is over the age of 55. As a result, a significant percentage is approaching full retirement age and quite a few of them can scarcely wait.

In addition, a high percentage of physicians are facing burnout and are ready to retire early. As we have seen, surveys show that over sixty percent say they would retire early, if they could afford to do so.

With the older adult population growing, the demand for physicians will intensify over the coming years.  According to American Association of Medical Colleges estimates, the United States faces a shortage of more than 90,000 physicians (of all specialties) by 2020 – a number that will grow to more than 130,000 by 2025.

The surveys indicate that as many as 60 percent of physicians over the age of 55 will retire in the next three years. The more seasoned physicians, who have already endured the transition to electronic medical records, the advent of HMO’s, bundled payments, being acquired by a larger group practice, have too many battle scars to face another round of major change.

As I described my own circumstances in The Familiar Physician: Saving Your Doctor in the Era of Obamacare, my children are grown and off on their own. Moving away from the parental and financial responsibilities of child rearing and education are part, but hardly all of the reasons I regularly hold retirement debates with myself and often with my wife. I also understand and have personally experienced the sense of powerlessness many seasoned doctors feel. At this point, I don’t know too many colleagues who if they haven’t set a retirement date in stone, have at least penciled it in on the calendar.

Retirement may seem a long way off to many physicians who have been practicing only a short time. But for those on the cusp, the challenges inherent in health care reform and the need for re-invention on a number of levels may prove a strong enticement to emulate Elvis and simply leave the building.

Malpractice in Primary Care

The Nine Forces Converging On Primary Care: #7 Malpractice And The Specter Of Defensive Medicine

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.

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