Home Forums Discussions General Discussion Frustrated!!!!!

1. I see 20-25 patients a day right now. I have seen colleagues of mine see 60 patients in half a day. I just can't figure out how they are doing this. One medicare pt I have , "I am here for my Physical exam, all my med refills, and I have 2-3 other problems since I am here",can eat up a lot of time. Do you know anyone that sees 40+ patients a day and how do they do it? Also, these guys can see the 60, review all the labs and xrays that go with it, and still be finished by 5pm.

tvo7,

I am impressed you can see 20-25 a day, I'm darn lucky if I see 15. But I am old and slow and even though my medicare is 28% of my practice, on a typical day about two thirds are medicare patients, and usually seeing about 4-5 annual wellness visits that I tie with a modifier with a 99213 because of the chronic problems. I've got about 1500 patients and only so many days in a year to get to the annual exams, and I don't know of anyone seeing 40 plus a day except one of the opthamologists.

The only way to see huge numbers of patients is to practice lousy medicine. Pity those that do; don't envy them. I can't do a blood pressure recheck in under 15 minutes.

I am more envious that they can see that many and still get get done in time. I struggle just to keep with 25 with so many of the patients bringing in the "by the way, I got this problem also"
Some of these large group clinics I see force the employed fp's to see 40-50 a day.

Dave said it. High patient volume in short periods of time = crappy medicine.
Having said that I average about 30 per day, but my hours are 6am-4 or 5pm (depending on need), 20 min apt's and 40min for physicals or really complicated pt's.

One of my mentors saw 60 per day, spent about 5 min with each, and prescribed opiates to everyone with an ache and antibiotics to everyone with sniffles. Not exactly the qualities that I chose to emulate.

Be proud that you are taking good care of your 20-25 pt's per day. Maybe you should sit in for a few of those high volume visits and take notes on how many patient questions are ignored by your colleagues.

tvo, sometimes it is all about having the right technology. Your colleagues who see 50 patients a day have certain advantages. With these, you can see just as many.

F'ing hilarious Jon!

Or just post this sign in the rooms:

tvo, where are you located btw.

We see between 6-10 patients a day and schedule 1/2 or 1 hour appointments. See patients 4 days a week and sleep well at night knowing we are practicing the best medicine we can. By the way we hope our rewards come from from heaven.

Yes and the docs who see 40-50+/day are now getting rated on quality - they now sit at meetings with the jaw open and say "I cant believe they dinged me for this and that"...oh yeah...one doesnt even have an operational plan on most disease systems and writes 4 lines of illedgible jargon and moves on to the next poor person who thinks they are getting good care.

Todd is right about the quality. In the internet age, anyone of your patients can leave you a negative rating which may or may not influence your future new patients. You should monitor your feedback on healthgrades.com or vitals.com.

The problem is that those guys seeing all those patients are getting good ratings. At least good enough for droves of people to fill their exam rooms. "I had a short wait, he gave me my prescription and I was back at work! He's awesome!" This being from a patient who self-diagnosed their illness and treatment from the internet, told him what they wanted and he gave it to them.

Tvo,

I have been chewing on this for a day, and it deserves a whole lot more than a one-liner. Since I have a break, I'm going to try.

The real issue is, of course, not that you envy his ability to spend only 5 minutes with a patient; you envy the fact that he is rewarded for doing so. And that really is the crux of the problem.

There is a physician in town who, like me, comes from an age and program where we were trained and credentialled in GI endoscopy. Like me, he continues to do so. Unlike me, however, every patient coming under his care, for whatever reason, gets both an upper and lower endoscopy. Every one. And, likely more than once. I once had a patient move to my practice and ask if he really needed a third gastroscopy that year for his heartburn. How do you tell that person that they never needed one at all? Yet, this doctor has a number of patients that give him high marks because he is so "thorough."

I try to follow guidelines pretty strictly, not just because it is good medicine, but because I recognize the terrible conflict of interest it sets up in me when I am self-referring for a procedure. Still, I cannot totally help wondering what my income and lifestyle would be like if I emulated my colleague.

Irritable bowel syndrome is a really pretty common condition that we all see. This is what UpToDate says about the appropriate care:

Therapeutic relationship ? The most important component of treatment lies in the establishment of a therapeutic physician-patient relationship. The doctor should be non-judgmental, establish realistic expectations with consistent limits, and involve the patient in treatment decisions [1]. Patients with established, positive physician interactions have fewer IBS-related follow-up visits

How effective would you, I, or Jon be if we tried to do this in 5 minutes?


The reimbursement system in which we find ourselves has been set up by accountants and lawyers. They have never been part of a profession or priesthood where honor and trust are everything. I do not think that those among our profession who follow the black-light arrow around the corner and join them are efficient. I do not think they are "moving with the times". I do not even think they are lost and misguided. I think they are Evil. I feel of them the same as when I turn over a wet rock and see some slimy, crawling thing wriggle away out of the light. I feel revulsion.

Yes, I envy my colleague when he brags about his villa in Spain. But I have no wish to follow him. I hope you don't either.

tvo7,

What David is saying has jarred my brain a bit. I think he is really onto something. I wanted to take an astronomy class my last semester in college, as I had all my core subjects met, but it filled up too quickly but we had a hot shot Prof trained at Harvard who taught existentialistic theology. Strange, but decided to take the course (1986)even though I was anything but theo-anything. We studied Buber, Kierkegaard, Tillich. I really enjoyed the course but things got filed away in the vault till I met a Lutheran in the late 90's, and wanting to understand more about Luther decided to read most of his teachings (that were translated from german to english) the raw stuff he was teaching his students at Wittenberg in the early 1500's. I think there are over 40 volumes, and I read most over a decade ago. But this idea of bondage of the will as Luther taught as well as having two opposing forces (sinner/ saint) present in an individual has subsequently intrigued me. What David is saying about pure Evil smacks of Lutherian thought, and I suspect Luther would argue the revulsion David feels towards this Evil may be the Good that drew him to this wonderful profession in the first place.
I also love Sarte and Camus--so its just not the theologians that have things to offer--

I did follow one of them when I was in residency.
This is his med f/u visit on a patient.
1. nurse does vitals and gets all the rx ready and had the rx on the chart ready for him to sign.
2. he walks in to the room and says Hi how is family etc. Told pt, your bp is good and we will be rechecking your chol.
3. Does not even listen to the heart, lungs, or carotids. Doesn't even touch the patient. Just looks at the nurses vitals.
4. Hands the signed rx over to patient and says see you next time.. Total time spent 2.5 minutes and on to the next patient.

Am I overdoing my bp and chol visit? Or is this this the standard for a bp and chol recheck?

Sometimes this board runs the gamut of responses? from the ridiculous (that was mine) to the sublime (David and Jimmie).
The draw of the ?dark side? is ever present and can be insidious. I don't think people generally go into medicine to be greedy bastards; sometimes it just gradually happens. I know David is not picking on gastroenterologists, but the precariousness of our situation is easy to understand. The lopsided reimbursement system is part of the issue. My wife (an internist) spends 40 minutes sorting out the patient?s various medical issues; I spend 5 doing an upper endoscopy and I get paid several times what she gets. Throw in the fact that the anxious patient may feel better after having had the procedure, and is it any wonder that some people make the choice to inappropriately scope rather than to talk? David, you probably spent more time talking that patient out of having an upper endoscopy than it would have taken to do one; and you are left with the uncomfortable worry that he thinks you aren?t ?careful enough?. So much of what we need to do involves education of the patient. Sadly, that is not part of the reimbursement scheme; unless you bill for ?counseling?. You certainly can?t do that with a 2.5 minute visit!

David, your example of irritable bowel syndrome treatment is well taken. Really, though, take that quote (?The most important component of treatment lies in the establishment of a therapeutic physician-patient relationship. The doctor should be non-judgmental, establish realistic expectations with consistent limits, and involve the patient in treatment decisions [1]. Patients with established, positive physician interactions have fewer IBS-related follow-up visits?) and isn?t it nearly equally true of managing diabetes, anxiety, obesity, and maybe even hypertension?

tvo, I think you know the answer to your questions. You are doing it right; what you describe IS "standard"...for a crappy doctor providing lousy care.

Hi everyone,

This has been an excellent thread, with numerous extremely well thought out replies.

I'm really not making any of these comments to brag. I'm sure that David or Jon or Jimmie or Adam or Todd could probably write exactly the same.

I am a 55-year-old solo family physician. I'm just short of my 25th anniversary in practice. My practice is much closer to a typical internal medicine practice, with older patient population, numerous medical problems, and numerous medications. Additionally, we are in a rather impoverished area, with high unemployment, much disability, lots of psychosocial problems, depression, and substance abuse issues.

I will typically see 25 to 30 patients daily, four days a week. Most of these are time and energy consuming, the easy ones we usually handle over the phone. At the end of the day, I am typically exhausted. But I believe I can truly say that I did my best for just about every patient I've seen.

What our patients need is our caring and our time. They need understanding, explanation, and reassurance. They need their medications reviewed, to try to figure out which other symptoms are coming from our best (or worst) efforts. They need us to listen to try to determine whether they need MRI, a referral, or an antidepressant (usually the latter.) They need us to be honest with them, to use our judgment, and for us to tell them what we really think they need or don't need, based on medical likelihood, not based on our chance of being sued. And they also need us to be able to tell them when they are approaching the end, and that we will provide care to the end.

In terms of cost to the system, I believe that the care that I (and probably most members of this forum) provide is extremely cost effective. This is not shown in the quarterly statements I get from the managed-care companies, looking at my immediate cost. But in terms of preventing hospitalizations, preventing unnecessary procedures, minimizing referrals, and overall keeping people healthy, I think I'm a huge bargain to the insurance companies.

Economically, I, too, am struck by the unfairness of the payment system. As many have observed, procedure oriented specialists, and surgeons make much more than I do.

But what else can we do? If you see the patient as a person, if you believe the Golden Rule is not just a nice saying, and (for some of us) if you believe that each of us was created and designed by God, and that Jesus gave his life for each of us, there is no choice in the matter. We have to practice the way we do. There is no other choice.

I, too, have been honored to participate in this User Board. The collection of wisdom, not only about electronic medical records and computers, but about medicine, finances, and life, found here is extraordinary. The willingness of users to share their knowledge, and contribute their time and talents, goes hand-in-hand with the willingness to provide excellent care to patients.

Thanks to all.

Gene

I have another tale, in case these discussions seemed all too theoretical. It is not a tale of medical brilliance. If it were to be starting its own thread, I might call it "in the land of the blind.... a tale of medical mediocrity".

Yesterday I saw another new patient who came to see me because of a rash and weakness of 2 1/2 months duration. He had been under the care of one of our "rapid encounter" providers about 3 times. Got a Medrol pack twice, the third time some lab was ordered. 5 minute visits, which I am sure their software justified as a level 4 every time.

When he saw me he had a blood pressure of 60/40, and I had some of my own stat labs drawn before delving more deeply in to the history. When I found he had labs drawn a week and a half ago, I asked my nurse to get a release and get them faxed over. We hit a lot of resistance... "what sort of doctor is Dr. Grauman? What does he need it for?...Well, Dr. X hasn't signed off on them yet...." We insisted, and finally Dr. X came on the line. Turns out no one had looked at the lab in the week and a half since they were drawn, and his creatinine was 12 with a BUN 0f 117. The provider's comments was "well, usually the lab is supposed to call if values are out of range..."

Our labs came back worse. Creatinine of 16, and now potassium of 6. I arranged the predictable things; go to the ER, arrange for transfer to a center with full time nephrology and dialysis. Took me a little over an hour.

At no point in this encounter did I feel I exhibited more than the bare minimum of competence and involvement. I realized the guy was sick, drew basic labs, and got recent old records and looked at them. I have no idea why this guy has suddenly gone into acute renal failure; it is some illness associated with a non-specific rash and renal failure is all I know at the moment. Wiser physicians that I will figure this out as they dialyze him and work him up, and it will probably prove to be a classic case of something or other, and I will feel like a moron for not having thought of that. But, I will feel a bunch better than his 5 minute provider. Hopefully.

Leslie is totally correct. It is really a great feeling when you snatch some poor, quivering soul back from the edge. But when you get there on the back of someone else's 5 minute display of absolutely stunning indifference and sloppiness , and without a hint of stretching your training or skill, it spoils all the fun.

I had a non impressive doc on staff at my medical school and I can't even remember his name or where he was from. But I do remember what he told me during my brief stent in his clinic. He said always listen to the patient, just spend time with them and they will tell you what is wrong with them.
I think it is often too easy and sometimes lucrative to order things to figure out what is going on.
But I think you did what is sometimes the hardest to do, spend time and give a damn. Cudos to you David.

David,

Good work, because you took the time to listen and care.

Unfortunately, so often the most "interesting cases" end up being the worst for the patient.

Gene

Ahh, but the point is, I did not do especially good work, I did absolutely mediocre work, what I consider the bare minimum to justify calling myself a doctor. It is the fact that we know there are lots of providers out there that do so much worse in the name of "production" that is appalling. And, to whatever degree the EMR aids that sort of behavior, I feel it bears part of the blame.

I see what you are saying but you still gave a damn and that often time trumps brilliance, or even good work, but the EMR has to be an AID and it will always be an aid to what WE do.

Wrong!! You did what was necessary, in a timely fashion, and got him plugged in.

ER care is also getting scary, we have 2 basic models. One is to do every test imaginable, mostly unnecessary, the other is to do nothing and send them out.

Seems like the well people get the first option, and the sick get the second.

Example: Obese 40 YO woman presented to ER with multiple sx, including dyspnea. Sent home with Antivert. Drove 40 miles to another hospital, ER there dxed saddle pulmonary embolism.

Fortunately she did well.

Gene

Also the EMR debate could be like the gun debate--do guns kill people or do people kill people.
I think the EMR is only a tool, just like a gun, it is who is operating the EMR or gun that can make it save a life or take one.

Damn, Jimmie, that hurts. As a second amendment guy, I can only roll over and die before that one. :-)

Sorry David,

I've always had a fear and not a great love for guns, but when my 11 year old wanted to take hunter education this year i took it with him (i had never taken a course like it)and was really bowled over with the course itself and instructors.
the basics that were taught can be applied to most any arena in life, but the personal responsibility, being taught to the 20-- 11 year olds and 1 old guy, was refreshing to be a part of.
But here in montana I have a can of the super powerful bear spray at my bedside which in a pinch will be the first defensive weapon of choice, but having a 20 guage shotgun is my second, which will deter most home invaders.
I hope I'll never use either one in a defensive way, but I like having the option to.

Unfortunately it is not really either --- it is either bad people with guns kill people or uneducated people with guns accidentally kill people.

Steven,
I stand corrected--

"Guns don't kill, bullets kill people" (or 00 buckshot, jimmie).
As one of the delegates to the CMA (some good guys have to go) I seethe at the innumerable anti-gun resolutions introduced at the annual CMA House of Delegates. I joked that I would submit a resolution (to become CMA policy) that "Resolved: the CMA support bullet control" (leading off the "Where as" with my first statement above)
Darned if the California legislature didn't beat me to the punch and actually passed laws making is harder to get ammunition!!

Agreed. So shouldn't we try to keep the guns out of the hands of the bad people and the uneducated people?

And, EHR's out of the hands of those that would abuse them as well? Hence my silent campaign to rid the world of templates and checkboxes....

I can tell you his name. It was William Osler, and he was from Canada.

And he taught not very far from where Jon (JBS) practices.

Gene

That is very true. He was the father of the residency. Which is why I don't like him.

David,

Thanks for bringing that up today about the sloppy care. It is nice hearing those kind of events, in the sense that it gives me a better appreciation for what we all do day in and day out. After hearing your situation, I made it a point and thanked every one of my patients for coming in and trusting me enough to be their doctor, and keeping me employed--the old bread and butter comment.
And sorry my fingers move faster than my brain, and I am really not quite sure how I made the transition from EHR to the 2nd ammendment.
I have to slow down and think these fleeting thoughts through before typing--but I agree their are definite differences in an EMR and if you have one that monopolizes your time to make the documentation and leaves little time for patient care then situations as you describe will occur more commonly than not, and the nice little thing about AC is that I can really focus and spend more quality time just BS'ing the patient and often time that's when their guard goes down and then they tell you why they are really there.

Jimmie,

No apologies. You statement was totally apropos. The EMR is just a tool, to be used for good or ill. But, here I go in my Cassandra mode again..

I only wonder... before the EMR, was it possible to see 60 patients a day and be that sloppy? Or did the fact that you needed to actually create even a minimal note maybe slow you down just enough to think about the issue, if even for a moment? I find if I do not use a template for my physical, for example, I have to think for at least a few milliseconds about what the heart really sounded like, or the neck felt like. I may miss some bullet points, but what is there sure seems more accurate. By not templating, it makes my note a little later in the day kind of like a mini-presentation to an attending... me, in this case. It is where my serious thinking get done. Speaking for myself, at least, I cannot imagine feeling "done" when I walked out of the room.

Well, they try but the NRA and the GOP block all efforts to have laws to keep guns out of the hands of bad people. But let's not hi-jack this thread and turn it into a political debate.

I have always seen fewer patients than some in order to practice better medicine & was making that work well until we started using AC 9 months ago. I cannot understand how they can clain to have such high user satisfaction when what we have experienced has been a NIGHTMARE of DAILY problems, getting charts in progress booted off for no apparent reason, getting a "not Responding" signal for unknown reasons, achingly slow transitions from one textbox to the next (I hate to click on orders, takes at least 10 seconds for it to pop up every time) features like a patients pharmacy preference NEVER showing up as supposed to, etc, etc. When we take time to call & complain, we get "that's a known problem & we're working on that" and STILL not fixed months later. My practice of 5 is LOSING MONEY now & I blame it all on AC. I would quit in a heartbeat if we hadn't spent so much time & effort & money on this product.
ANYBODY ELSE FEEL THIS WAY?

HealthyPearls,

First, welcome to the AC User Board, your first step in correcting your issues. I have none of those problems.

Also, every problem you have noted has been fixed by users many, many times on the user board. While the AC tech support knows many things about AC, given they are not actually users, using the program on a day to day basis, I think they don't always know the answers that the should.

One thing, I should say right off, is I have never seen it take time to transition from one textbox to the next. Do you mean if you tab in the HPI box, it takes time to go to the Review of Systems. That should be quicker than instantaneous and, in fact, have never heard of that complaint.

I have looked at many EMRs, and have been on AC longer than nine years. It is, by far, the quickest.

A few questions:

1. Are you using 6.12?
2. Are you using wireless? (If so, change to wired as soon as possible).
3. What OS are your clients using and actual model (home vs pro).
4. What NIC cards are you using on ALL your clients, e.g. 1Gb or lower?
5. What speed are you using on the NIC card on your main computer, e.g. 1Gb or lower?
6. What speed are you using for your switch?
7. How much RAM on clients and how much RAM on the main computer?
8. Are you using P2P or are you using Client/Server?
9. Do you know what processors you are running on your computers?

I have to say I have heard many complaints over the years about someone's AC. But, no one has ever contributed decreased income due to it.

The issue with the pharmacy is one that happens for some and not for others. But, other than that and I am not saying you are wrong or do not have legitimate points, but many on here will blame Amazing Charts and SQL Server on all their problems, when many times it is the network. Many times.

5 providers all on the same server? You definitely need a proper network for that to function properly.

You should go through Bert's list so we can pinpoint the problem. He's probably right about the network.