Jun. 28th, 2020 09:07 pm
What does your doctor do all day?
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nightengaleskndExcept for people who themselves work in health care, I don’t think most people know much about what doctors do when not in the room with their patients. And a lot of people’s perception of doctors comes from TV. Most TV doctors work in hospitals. When a show features a TV doctor in an office practice, he (at least I can’t name any female TV doctors who practice outpatient medicine) sees a patient and then sees a patient and then sees a patient. Often, they show banter between the doctor and office staff, before seeing more patients. Occasionally they show the doctor meddling hideously in the life of his patient by showing up at their house unannounced and uninvited.
I got to the office Friday morning a bit after 8 AM and left just before 6.
After doing the COVID things after arriving (taking off my cloth mask, washing my hands, putting on my medical mask) I met briefly with M, the nurse who works primarily with my practice and does the majority of scheduling. I’m never sure how to refer to her. I hate the implication of “my nurse.” But there are other nurses in our office, so I can’t say “our nurse” or “the office nurse.” Anyway, she’s the glue that holds the practice together, especially now that I am working from home most days. She handles all phone calls, paperwork in and out and gets vitals.
She has a checklist of questions to ask the family of new patients, to make sure they are appropriate for the practice. There’s a new patient on my schedule I don’t know anything about, so she shares the intake checklist with me. We discussed how many new referrals she was getting and some options to revise the schedule if I add another day in the office that is currently tele-health. I put away the toys that I washed last week and left to dry and reviewed the note I’d written for my follow-up patient’s last visit.
I saw 3 patients. I have a specialty practice with long visits. I’m currently see up to see 4 patients on an office day, and 6-8 patients on a tele-medicine day. Two were new patients, with 90 minute visits. The third was a follow-up, with a 45 minute visit. We’re leaving extra time between patients so they don’t run into each other in the hallway. At each visit, I got historical information, examined the child, played and interacted with the child, made recommendations verbally, wrote down my recommendations, printed them out and handed them to the family. I accounted for my time spent in two places, an online billing step that is part of the electronic medical record, and then separately on paper.
This, by the way, the time spent in the room with a patient, is the only thing I did all day which can be billed to insurance.
So that was 3 and a quarter hours providing direct care for patients. I was in the office nearly 10 hours.
What else did I do?
I washed all the toys still left in my exam room twice with soap and hot water. I have removed most of the toys due to COVID but left a few plastic ones. The first time, I dried them with baby blankets because we are out of towels. The second time, I left them to dry until I am back in the office. I got antimicrobial wipes from another exam room and used them on my stethoscope, reflex hammer, ophthalmoscope and a board book I use to assess language skills of young children.
I refilled prescriptions for 7 patients. At my current office, I can do this electronically now, which saves some time. For each prescription I check the dose from the last visit or phone message with the family and also how long it has been since the last visit. If it’s been too long, I message M to ask the family to schedule a follow-up.
I spoke with six families on the phone. I made recommendations to adjust medication for three of them. I also went over recent lab results for one of these. I advised one family to contact their pediatrician to address the problem they were describing because it sounded like a medical problem that was triggering the behavior change. (Up to 30% of “behavior change” in people with developmental disabilities can be attributed to medical problems, in one study. I’m not 30% good, but I do identify a potentially treatable medical explanation pretty often.) The fifth family was requesting a prescription for in-home behavioral services, which I will write over the weekend. The sixth was giving me an update on a recent hospital admission. The shortest phone call was probably 10 minutes.
I completed FMLA paperwork for one child and signed a PT prescription for another. I completed these after the office staff left for the day, so I put a post-it on the pile saying “please fax.”
I also got some labs off my desk I had already discussed with the child’s family, and a happy-gram from an insurance company telling me my patient was on 3 different mental health medications and I should contact them if I want help managing his condition and medications because polypharmacy is a problem. I mean, yes, polypharmacy is a problem. I sincerely doubt that anyone at the help-line at the insurance company would have an effective fewer-medication strategy. Those papers went into another pile with a post-it saying “please scan.”
M grabbed me to talk about a new referral from another office in our practice. The description sounded as though the patient might need more urgent and different care than I provide. I spoke with the nurse who had made the referral about my concerns.
I received a subpoena faxed from family court asking me to testify about a patient. I contacted my manager who said “can you scan them in and e-mail them to me?” I don’t know, could I? I didn’t know how to scan documents into e-mail in our office but our scheduler scanned them for me. I e-mailed them to our manager who forwarded them to legal.
I printed out the recommendations I had for a new patient I had seen by telemedicine earlier in the week so it could be mailed to his family.
Mid-morning, I received notice that a medication I had prescribed needed a prior authorization. I had already submitted the prior authorization for it on Monday. The patient has two insurance companies. The primary insurance had covered the medication except for the co-pay. Yesterday, the secondary insurance contacted me requesting proof that the primary insurance had paid for the medication. I probably spent twenty minutes on the phone with them yesterday. They told me the pharmacy could call them with this proof. Yesterday, the pharmacy told me they would do this. Today I received a new request for a prior authorization.
So shortly after noon, I called the insurance company. I input my medical ID number, patient’s insurance number and date of birth into the electronic system. When a person answered, he asked for all these numbers verbally, along with my name and the patient’s name. I told him the story. First he said the medication had been covered on Monday. I asked why I got a fax stating it wasn’t. I read him the fax. He said they then learned they weren’t the primary insurance and needed proof the primary insurance had or hadn’t paid. I stated the pharmacy was supposed to have called yesterday with that information. He said he saw a claim but not proof of payment. I asked to speak with someone who could resolve this without my spending 30 minutes on the phone with the primary insurance trying to get written proof sent to me to send to them. Could I at least have the primary send them that information directly? He put me on hold. He came back. He found an override had been put into the system showing the medication had been paid for yesterday and had been authorized for three months. He couldn’t provide me with a reasonable answer why he hadn’t seen this information earlier in the call. He couldn’t guarantee I wasn’t going to have to go through this same whole process in three months. He couldn’t explain why it was approved for three months rather than a year as it typical. He could not reach a supervisor but took my name and e-mail address. Then I called the pharmacy to make sure they had been notified. The entire process today took 50 minutes. In other words, I had a prior authorization for lunch.
(The entire process, over the course of this week included
1 phone call to the primary insurance
3 to the secondary insurance
3 to the pharmacy
30 minutes filling out the form (requesting names, dosages and dates of all prior medications tried and why they didn’t work, vital signs and lab values)
And in addition to my time, time spent by M faxing the office notes including vital signs and lab tests to the insurance and scanning all these faxes into the system
The TV show, “New Amsterdam,” which has serious serious serious “hospitals don’t work like that” problems (https://nightengalesknd.dreamwidth.org/#entry-106107) , had an episode where the executive director of the hospital called an insurance company. They showed him getting stymied by the phone tree and the denials based on protocols delivered by non-clinicians. I cheered at the representation of my days. Then they showed him going physically to the office of the insurance company and demanding to be heard, and eventually winning. Sigh. Hospitals (and insurance companies) don’t work like that.
I sent two e-mails and received one about a message from IT about something I might need to install, that might not be accessible for me. Without this thing, I won’t be able to access the website I use to check potential drug interactions and prescription recommendation, nor the website where I can read full-text of articles in the literature, nor open links e-mailed to me by the hospital system where I work. It currently takes me about 5 minutes to get to any of these sites, partly due to accessibility issues.
Around 5 PM, I realized my ID badge was no longer attached to my lanyard. I can leave without the badge but will need it to get back into that building next time. I looked in my office, the exam room, the front desk area. Again in my office, the exam room, the front desk area. The toy containers in case it had fallen off and swept into one of those. My tote bag. Pockets. Finally found it stuck in the handle of a drawer in the room where I had gotten the anti-microbial wipes.
If I had had more patients in the office today, these other things would still need to have been done. Most of them couldn’t be put off until Monday. I would have simply stayed later on the phone and refilling medications.
I am home now, and had something to eat and am reading the news of the day. I need to send an e-mail to a colleague about the new referral with the potentially urgent problem. And I have about two hours of charting to do on patients seen earlier in the week, because we have 4 days to complete office notes and I’ve been busy earlier in the week seeing patients, calling patients, calling insurance companies and attending a virtual professional conference in my field. It takes me about two hours to write a report on a new patient, which is slightly above average for doctors in my field. It takes about 20 minutes to type up a note on a follow-up patient, which is just about average for doctors in my field. This week I saw 15 follow-ups and 3 new patients. That’s a guaranteed 11 hours typing in store. If I’m too tired to do that typing at night, which I often am, that’s Saturday and Sunday’s plan.
Several years before I started medical school, I had a shadowing opportunity with an OB-GYN. I have two memories of that day. I learned about the use of extra birth control pills as emergency contraception (this was years before Plan B was commercially available over the counter) That was the clinical thing I learned. But the main take-away for me was not a clinical pearl. It was watching the doctor spend the day on the phone with an insurance company. Most of the time she wasn’t in the room with a patient, she was arguing with this insurance company. She wanted a medication covered that was expensive. I can’t remember her name or the name of the medication but I can hear her on the phone. “Yes, I’m aware it’s expensive. The alternative would be to put her in the hospital and give her blood transfusions, which is riskier and even more expensive.”
I don’t know if that’s what your doctor does all day. It’s what she did. It’s what I do. I wish I could do more taking care of patients and less arguing with insurance companies, but right now, arguing with insurance companies is part of taking care of patients. So’s all the rest of this stuff. It would be nice if at least the phone call time could be reimbursed. It will be nice when we have a portal where I can message families instead of some of these phone calls.
I have about 350 active patients. I saw 3 of them today. I interacted with or did something on behalf of 20 of them. That works out to about 5%. It will take 600 patients to reach our goal of having my schedule completely full. That will mean more time in the day seeing patients, and more patients who need things done in the minutes before, between and after patients. I tell my patients they can call any time with problems or concerns, and that I would be happy to sign their FMLA forms and their therapy referrals. And I mean it.
I’m just not quite sure when.
I got to the office Friday morning a bit after 8 AM and left just before 6.
After doing the COVID things after arriving (taking off my cloth mask, washing my hands, putting on my medical mask) I met briefly with M, the nurse who works primarily with my practice and does the majority of scheduling. I’m never sure how to refer to her. I hate the implication of “my nurse.” But there are other nurses in our office, so I can’t say “our nurse” or “the office nurse.” Anyway, she’s the glue that holds the practice together, especially now that I am working from home most days. She handles all phone calls, paperwork in and out and gets vitals.
She has a checklist of questions to ask the family of new patients, to make sure they are appropriate for the practice. There’s a new patient on my schedule I don’t know anything about, so she shares the intake checklist with me. We discussed how many new referrals she was getting and some options to revise the schedule if I add another day in the office that is currently tele-health. I put away the toys that I washed last week and left to dry and reviewed the note I’d written for my follow-up patient’s last visit.
I saw 3 patients. I have a specialty practice with long visits. I’m currently see up to see 4 patients on an office day, and 6-8 patients on a tele-medicine day. Two were new patients, with 90 minute visits. The third was a follow-up, with a 45 minute visit. We’re leaving extra time between patients so they don’t run into each other in the hallway. At each visit, I got historical information, examined the child, played and interacted with the child, made recommendations verbally, wrote down my recommendations, printed them out and handed them to the family. I accounted for my time spent in two places, an online billing step that is part of the electronic medical record, and then separately on paper.
This, by the way, the time spent in the room with a patient, is the only thing I did all day which can be billed to insurance.
So that was 3 and a quarter hours providing direct care for patients. I was in the office nearly 10 hours.
What else did I do?
I washed all the toys still left in my exam room twice with soap and hot water. I have removed most of the toys due to COVID but left a few plastic ones. The first time, I dried them with baby blankets because we are out of towels. The second time, I left them to dry until I am back in the office. I got antimicrobial wipes from another exam room and used them on my stethoscope, reflex hammer, ophthalmoscope and a board book I use to assess language skills of young children.
I refilled prescriptions for 7 patients. At my current office, I can do this electronically now, which saves some time. For each prescription I check the dose from the last visit or phone message with the family and also how long it has been since the last visit. If it’s been too long, I message M to ask the family to schedule a follow-up.
I spoke with six families on the phone. I made recommendations to adjust medication for three of them. I also went over recent lab results for one of these. I advised one family to contact their pediatrician to address the problem they were describing because it sounded like a medical problem that was triggering the behavior change. (Up to 30% of “behavior change” in people with developmental disabilities can be attributed to medical problems, in one study. I’m not 30% good, but I do identify a potentially treatable medical explanation pretty often.) The fifth family was requesting a prescription for in-home behavioral services, which I will write over the weekend. The sixth was giving me an update on a recent hospital admission. The shortest phone call was probably 10 minutes.
I completed FMLA paperwork for one child and signed a PT prescription for another. I completed these after the office staff left for the day, so I put a post-it on the pile saying “please fax.”
I also got some labs off my desk I had already discussed with the child’s family, and a happy-gram from an insurance company telling me my patient was on 3 different mental health medications and I should contact them if I want help managing his condition and medications because polypharmacy is a problem. I mean, yes, polypharmacy is a problem. I sincerely doubt that anyone at the help-line at the insurance company would have an effective fewer-medication strategy. Those papers went into another pile with a post-it saying “please scan.”
M grabbed me to talk about a new referral from another office in our practice. The description sounded as though the patient might need more urgent and different care than I provide. I spoke with the nurse who had made the referral about my concerns.
I received a subpoena faxed from family court asking me to testify about a patient. I contacted my manager who said “can you scan them in and e-mail them to me?” I don’t know, could I? I didn’t know how to scan documents into e-mail in our office but our scheduler scanned them for me. I e-mailed them to our manager who forwarded them to legal.
I printed out the recommendations I had for a new patient I had seen by telemedicine earlier in the week so it could be mailed to his family.
Mid-morning, I received notice that a medication I had prescribed needed a prior authorization. I had already submitted the prior authorization for it on Monday. The patient has two insurance companies. The primary insurance had covered the medication except for the co-pay. Yesterday, the secondary insurance contacted me requesting proof that the primary insurance had paid for the medication. I probably spent twenty minutes on the phone with them yesterday. They told me the pharmacy could call them with this proof. Yesterday, the pharmacy told me they would do this. Today I received a new request for a prior authorization.
So shortly after noon, I called the insurance company. I input my medical ID number, patient’s insurance number and date of birth into the electronic system. When a person answered, he asked for all these numbers verbally, along with my name and the patient’s name. I told him the story. First he said the medication had been covered on Monday. I asked why I got a fax stating it wasn’t. I read him the fax. He said they then learned they weren’t the primary insurance and needed proof the primary insurance had or hadn’t paid. I stated the pharmacy was supposed to have called yesterday with that information. He said he saw a claim but not proof of payment. I asked to speak with someone who could resolve this without my spending 30 minutes on the phone with the primary insurance trying to get written proof sent to me to send to them. Could I at least have the primary send them that information directly? He put me on hold. He came back. He found an override had been put into the system showing the medication had been paid for yesterday and had been authorized for three months. He couldn’t provide me with a reasonable answer why he hadn’t seen this information earlier in the call. He couldn’t guarantee I wasn’t going to have to go through this same whole process in three months. He couldn’t explain why it was approved for three months rather than a year as it typical. He could not reach a supervisor but took my name and e-mail address. Then I called the pharmacy to make sure they had been notified. The entire process today took 50 minutes. In other words, I had a prior authorization for lunch.
(The entire process, over the course of this week included
1 phone call to the primary insurance
3 to the secondary insurance
3 to the pharmacy
30 minutes filling out the form (requesting names, dosages and dates of all prior medications tried and why they didn’t work, vital signs and lab values)
And in addition to my time, time spent by M faxing the office notes including vital signs and lab tests to the insurance and scanning all these faxes into the system
The TV show, “New Amsterdam,” which has serious serious serious “hospitals don’t work like that” problems (https://nightengalesknd.dreamwidth.org/#entry-106107) , had an episode where the executive director of the hospital called an insurance company. They showed him getting stymied by the phone tree and the denials based on protocols delivered by non-clinicians. I cheered at the representation of my days. Then they showed him going physically to the office of the insurance company and demanding to be heard, and eventually winning. Sigh. Hospitals (and insurance companies) don’t work like that.
I sent two e-mails and received one about a message from IT about something I might need to install, that might not be accessible for me. Without this thing, I won’t be able to access the website I use to check potential drug interactions and prescription recommendation, nor the website where I can read full-text of articles in the literature, nor open links e-mailed to me by the hospital system where I work. It currently takes me about 5 minutes to get to any of these sites, partly due to accessibility issues.
Around 5 PM, I realized my ID badge was no longer attached to my lanyard. I can leave without the badge but will need it to get back into that building next time. I looked in my office, the exam room, the front desk area. Again in my office, the exam room, the front desk area. The toy containers in case it had fallen off and swept into one of those. My tote bag. Pockets. Finally found it stuck in the handle of a drawer in the room where I had gotten the anti-microbial wipes.
If I had had more patients in the office today, these other things would still need to have been done. Most of them couldn’t be put off until Monday. I would have simply stayed later on the phone and refilling medications.
I am home now, and had something to eat and am reading the news of the day. I need to send an e-mail to a colleague about the new referral with the potentially urgent problem. And I have about two hours of charting to do on patients seen earlier in the week, because we have 4 days to complete office notes and I’ve been busy earlier in the week seeing patients, calling patients, calling insurance companies and attending a virtual professional conference in my field. It takes me about two hours to write a report on a new patient, which is slightly above average for doctors in my field. It takes about 20 minutes to type up a note on a follow-up patient, which is just about average for doctors in my field. This week I saw 15 follow-ups and 3 new patients. That’s a guaranteed 11 hours typing in store. If I’m too tired to do that typing at night, which I often am, that’s Saturday and Sunday’s plan.
Several years before I started medical school, I had a shadowing opportunity with an OB-GYN. I have two memories of that day. I learned about the use of extra birth control pills as emergency contraception (this was years before Plan B was commercially available over the counter) That was the clinical thing I learned. But the main take-away for me was not a clinical pearl. It was watching the doctor spend the day on the phone with an insurance company. Most of the time she wasn’t in the room with a patient, she was arguing with this insurance company. She wanted a medication covered that was expensive. I can’t remember her name or the name of the medication but I can hear her on the phone. “Yes, I’m aware it’s expensive. The alternative would be to put her in the hospital and give her blood transfusions, which is riskier and even more expensive.”
I don’t know if that’s what your doctor does all day. It’s what she did. It’s what I do. I wish I could do more taking care of patients and less arguing with insurance companies, but right now, arguing with insurance companies is part of taking care of patients. So’s all the rest of this stuff. It would be nice if at least the phone call time could be reimbursed. It will be nice when we have a portal where I can message families instead of some of these phone calls.
I have about 350 active patients. I saw 3 of them today. I interacted with or did something on behalf of 20 of them. That works out to about 5%. It will take 600 patients to reach our goal of having my schedule completely full. That will mean more time in the day seeing patients, and more patients who need things done in the minutes before, between and after patients. I tell my patients they can call any time with problems or concerns, and that I would be happy to sign their FMLA forms and their therapy referrals. And I mean it.
I’m just not quite sure when.
no subject
(Also, how stupid that we are taking someone who has all of that training in medicine and making them do paperwork - seems like a very poor use of their time, and very inefficient. Of course, my job description is basically 'do as much of the other random stuff as possible so that the scientists can spend their time focusing on science', so I'm bound to see it that way...)
no subject
no subject
Some day, I will meet the person who went into health care because they actually liked doing paperwork. I mean, the world is infinitely diverse. There has to be one, right?