Saturday, January 4, 2014

Paper Work and Phone Calls. A Day in the Life of a General Internist

Okay, So I was looking for pictures of a HARRIED DOCTOR and HARRIET from Doctor Who kept showing up.  Since I am a huge Doctor Who fan, I decided to put it up.  

A Day In the Life of a General Internist

People wonder what it is that doctors DO all day, what our lives are like.  They wonder why we seem so BUSY all the time and why we don't return phone calls personally, or spend 45 minutes with each and every patient.

 It's really hard to describe because the work changes daily.

The other day, for example:I was awakened at 12:30 a.m. with an admission from the ER of a patient with a small bowel obstruction.  I've known him for a long time, and was able to give information without even looking at the chart.  I gave orders to a nurse who clearly was brand new.  After I hung up, I thought to myself, "I know she's going to wait 20 minutes, until I've just fallen back to sleep, and call me with a question."   Sure enough, at 1 a.m., the phone rang again and it was the nurse.  Fortunately, I've gotten REALLY good at falling right back to sleep.

I wake up at 5:30 a.m. for quiet time and wake up my son and husband at 6 a.m.  While my husband walks the dog, I'll make us breakfast, then I shower, and get ready to take my son to school.

If it's my late day, I start later in the office but work until 7 p.m. seeing patients. 
I'll work at home all morning finishing up my charting from the day before.  Charting requires doing a bunch of bureaucratic stuff to allow the bean counters to count things you did in order to justify your charges.  It's not just writing down what the patient said, what you found on exam, and what you want to do.  You have to write down a lot more than that.  You have to  justify your time to the insurance companies.  You have to figure out a diagnosis code (now called ICD-9 but is going to expand to a huge number of codes with more specifics called ICD-10 this year--requiring even MORE time to chart) and figure out what "Evaluation and Management" code to use.  Those are codes that say how much work you did to charge the patient/insurance company. 

I work part time which means that instead of working over 100 hours a week, I work 40-50, 24 of which are spent in the office just seeing patients, and the rest is on the phone, on the computer, charting, answering questions, and trying to deal with the inch deep pile of paperwork that comes across the fax or computer daily. (Paper free?  HAH!!)

Home visiting nursing orders.  These require me to periodically open up the chart and fill out a form for Medicare called the "Face to Face Encounter", to prove that I actually am seeing my patient and that they deserve to be in home care, and that I'm not committing Medicare Fraud.  It takes up to 5-10 minutes to fill out one of these forms and I get 3-4 a day.  I hate the Face to Face forms.

Physical therapy orders.  Written in another language, all acronyms.  I have to read and sign these.  

Xray reports.  I have to read, decide whether they need further action, and either call the patient myself if it's complicated or worrisome, or write a note to the staff to call the patients with results/instructions.

Lab reports.  I review these daily.  For diabetics, I have to enter the information into flowcharts on their charts.  Add 10 minutes each. Then I have to decide if I'm changing therapy based on the labs, write a note and either call or have the staff call the patient.  Half of my patients are diabetic.

Consult letters
.  I have at least 5-15 of these a day to read.  Many have requests in them, like, "please send the latest labs or xray reports."  I have to do that.

Emails from patients, and notes through the charting system from patients.  I get about 10 of these a day.  Some are urgent, some are not urgent.  I can't answer all of them the same day.

FMLA forms:  I HATE these forms.  The companies use these now to make the patients justify why and how often they'll be sick in the future.  I'm supposed to GUESS how often a patient is going to need to be off work based on a diagnosis.  If I'm wrong, the patients get penalized and I have to REWRITE a form with new guidelines.  I have 2-3 a week of these.  These take 20-30 minutes each to fill out.

Disability forms:  These come in many flavors.  There are short term forms for works, long term forms for work, State forms, Medicare SSI forms, Credit card forgiveness forms, etc.  I hate these too.  They all take 15 -30 + minutes to fill out.  

Handicapped driver placard forms:  These require me to open the chart up, search through it for diagnoses and reasons that someone needs a handicapped hanger or license.  These come in a flurry twice a year or so. If we give a placard or license plate to someone who doesn't qualify, we can get in big trouble. The criteria are very specific, and if the patient's health problems don't qualify, they cannot get one.

Phone calls. I get anywhere from 20-30 a day. Staff get calls from patients with questions.  With most, I can tell the staff what to tell the patient and the staff will call the patient back.  Some I have to call back.  Some INSIST that ONLY I call back.  Sometimes I HAVE to call people back because the issues are complicated or worrisome.  Sometimes I WANT to call back just to check in myself.  There are patients who NEVER call.  When they call, I worry. 

Seeing patients is my favorite part of the day.  What I really hate, is when my staff doesn't get my patient into the room in a timely fashion and makes me late through no fault of my own.  Guess who gets the grief?  You got it.  ME.  Now granted, there are times when I'm running behind because I've had a very complicated patient requiring extra time from me.  I ALWAYS apologize when I'm late, and make sure the next patient knows they'll get my full attention too.
Thinking about medical problems, trying to get to the real root of a problem, making complex diagnoses, these are the things I do best.  SOMETIMES there is a hidden agenda, like the patient is afraid they have cancer, but doesn't tell me.  I have to figure that out by LISTENING.  I love that part.  Listening, that is.

Listening entails WATCHING, HEARING, and NOT TALKING myself.  NOT thinking ahead of the next question to ask.  Lots of little clues are in the details of the story of the illness.

The electronic medical record is often a frustrating part of the visit for many of us now.  I can type as I listen.  I took typing in fourth grade (thanks Mom!).  The computer changed everything we do.  That is a whole 'nother post.

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