For New Doctors, 8 Minutes Per Patient

[Ericokle]

http://well.blogs.nytimes.com/2013/05/30/for-new-doctors-8-minutes-per-patient/

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[RadOncDoc21]

I spend more time dictating an H and P on a patient then speaking to the patient... Charting and documentation is roughly 90% of what I do.

 

[Neuronix]

I think the article is great at drawing attention to this issue. But, the article proposes things that won't fix the problem. The 80 hour work week has nothing to do with this. If the work hours are increased to 100/week, that will just be another 20 hours doing things other than spending time with patients.

The reality is that residents are income generators for the hospital. What generates revenue? Admissions with lengthy notes, imaging and lab tests, procedures, and rapid discharges. If you are an intern in medicine or surgery, your job generating revenue involves writing lengthy high level admission and progress notes, ordering and staying on top of imaging and lab tests, coordinating the consultants who do the procedures, and doing lengthy discharges (god forbid they get readmitted...).

The emphasis is on turning patients around as quickly as possible, so the job is to admit and discharge patients as quickly as possible. They often have chronic illnesses that don't need much actual history or physical exam work. Explaining things to patients or talking to them pays the hospital absolutely nothing. Nobody is going to tell you that you shouldn't take your time with patients directly, but they will call you slow and wonder why you spend too much time with patients if you do so. The reality is that as residents patients are scheduled or put on you too quickly for you to spend this sort of quality time regardless.

It's most time efficient not to ask patients questions, but have the note written before you even walk in the room. I was told as an intern that I should be aiming for level 5 consult notes every time, and that's what I did. So I would always get in and out of a room quickly and then write a note. With EMR, writing notes was supposed to be easier, but instead the notes are just lengthier, better written (better for malpractice in some ways), and generate higher billing. With EMR, the charting requirements just get higher, so while the efficiency for doing the same work improves, the bureaucracy increases with this efficiency so that there is no net gain. Not to mention all the headaches with the EMRs when they don't do what you want them to.

If you increase time in the hospital or bring in more residents, none of this will change. Spending more time in the hospital would simply mean being given more patient responsibilities that are the same (i.e. covering another service or more patients per resident). If there are more residents, that just means more services or patients can be covered.

The real way to fix the problem is to incentivize actually spending time with patients. It pays much better to see patients quickly than to see one patient for a long amount of time. It pays much better to write lengthy notes than short ones, regardless of how much time you actually spent with the patient. Residents allow attendings to see more patients and write better notes. This may translate to more time the attending spends with the patient or more time for the attending to do research. It may translate into better attending happiness and recruitment. But, the resident's primary job as a revenue generator by seeing patients quickly and writing lengthy notes is unaffected by anything proposed in that article.

 

[deleted307836]

Very insightful post, Neuronix - thank you.

 

[Bartelby]

I think Neuronix hit the nail on the head. Does anyone think the entire culture of what we do would change with 20 extra hours each week in the hospital? I'm convinced we would just have 20 extra hours of the same type of work. If we want to change how much time we spend with patients we have to change what we as a system value.

 

[FutureInternist]

If lawyers can get paid to think about a case, for doing research & for communications with clients, then why can we not get paid for counseling

The amount of health care maintenance issues we have to deal with at each visit, leaves little to no time for the actual complaint that the patient came in for
C-scope, mammo, Pap, PSA, Diabetic nerve check, depression screening, EtOH screening, domestic abuse screening, tobacco cessation..........(10 mins)
THEN you get to their HTN, DM, LDL control (since if your patients are not at goal you get paid less) - 5 mins
THEN you say "What brings you in?" - 10 point ROS for higher level of billing if you want
THEN physical exam
THEN med refills
THEN med reconcilliation
THEN....you get paid $5 if the insurance company says its OK

More reason to just go into a group, make a base & leave the worrying about reimbursements etc to the partners

I had clinic on Fridays during Residency so I got in the habit, early on, of calling my patients every Wednesday to get their CC, ROS etc, remind them to bring in their BP & sugar log
This was time consuming but ultimately saved time during the actual visit since I already had > 75% of their visit busy work covered.
Now in fellowship I do the same thing. Clinic on Wed so remind everyone on Fri to get their labs drawn (Nephro is NOTHING w/o labs !!). Saves me having to follow up on labs post-appt & calling pts back with new meds etc.

 

[dpmd]

If lawyers can get paid to think about a case, for doing research & for communications with clients, then why can we not get paid for counseling

When you are an attending, you can get paid for counseling sort of. There are a variety of codes that are based on time spent with the patient particularly if more than 50% of the visit is counseling/coordination of care. The kicker is that you can't bill for any of the time that was spent by the resident, so the choices are to do the counseling yourself, lie about it, or make sure the resident documents enough elements to bill high based on documentation instead of time spent. Actually, we are technically supposed to do the entire history and exam ourselves, but I challenge you to find an attending staff member that does this for every patient every time.

 

[Neuronix]

Actually, we are technically supposed to do the entire history and exam ourselves, but I challenge you to find an academic attending that does any of this for any patient ever.

 

[dpmd]

I was giving people the benefit of the doubt, but yeah.

 

[gutonc]

When you are an attending, you can get paid for counseling sort of. There are a variety of codes that are based on time spent with the patient particularly if more than 50% of the visit is counseling/coordination of care. The kicker is that you can't bill for any of the time that was spent by the resident, so the choices are to do the counseling yourself, lie about it, or make sure the resident documents enough elements to bill high based on documentation instead of time spent. Actually, we are technically supposed to do the entire history and exam ourselves, but I challenge you to find an attending staff member that does this for every patient every time.

I get paid for counseling, but what I'd really like to get paid for is the 3 or 4 hours I spend researching each new patient, reviewing their charts, labs and imaging, discussing their cases in tumor board and talking to referring docs and other consultants.

I generally document well enough to earn a 99205 without the counseling statement but that other time would be nice to get paid for. But only face-to-face time counts for billing.

 

[dpmd]

I get paid for counseling, but what I'd really like to get paid for is the 3 or 4 hours I spend researching each new patient, reviewing their charts, labs and imaging, discussing their cases in tumor board and talking to referring docs and other consultants.

I generally document well enough to earn a 99205 without the counseling statement but that other time would be nice to get paid for. But only face-to-face time counts for billing.

Could make the patient sit there while you do it, but I think that would make you unpopular.

 

[michaelrack]

Actually, we are technically supposed to do the entire history and exam ourselves, but I challenge you to find an attending staff member that does this for every patient every time.

The attending could get by basically reading back the resident's note to the patient:

"Mr. Smith, I see you are having chest pain down your left arm with sob, dizzyness, and fatigue- is that right? YOu have dm, copd, smoke but don't drink, correct? your mother had CAD? You're not having any diarrhea, bloody stools, dysuria?" Then lays stethoscope on patient for a few seconds.

Not that I would recommend doing this.

 

[FutureInternist]

The attending could get by basically reading back the resident's note to the patient:

"Mr. Smith, I see you are having chest pain down your left arm with sob, dizzyness, and fatigue- is that right? YOu have dm, copd, smoke but don't drink, correct? your mother had CAD? You're not having any diarrhea, bloody stools, dysuria?" Then lays stethoscope on patient for a few seconds.

Not that I would recommend doing this.

Thats what I did as an intern too
By the time we see the patient, they have reported their story to approx 5 people (Spouse, 911, EMS, ER triage nurse, ER resident, ER attending) so when you walk in & say "Tell me about your chest pain" they can get frustrated
I basically say something to the effect "I read your chart already & I will tell you what I know & you can tell me where I'm wrong & where you want to add something"
This speeds up the admission process substantially

 

[wild0ne]

I think the article is great at drawing attention to this issue. But, the article proposes things that won't fix the problem. The 80 hour work week has nothing to do with this. If the work hours are increased to 100/week, that will just be another 20 hours doing things other than spending time with patients.

The reality is that residents are income generators for the hospital. What generates revenue? Admissions with lengthy notes, imaging and lab tests, procedures, and rapid discharges. If you are an intern in medicine or surgery, your job generating revenue involves writing lengthy high level admission and progress notes, ordering and staying on top of imaging and lab tests, coordinating the consultants who do the procedures, and doing lengthy discharges (god forbid they get readmitted...).

The emphasis is on turning patients around as quickly as possible, so the job is to admit and discharge patients as quickly as possible. They often have chronic illnesses that don't need much actual history or physical exam work. Explaining things to patients or talking to them pays the hospital absolutely nothing. Nobody is going to tell you that you shouldn't take your time with patients directly, but they will call you slow and wonder why you spend too much time with patients if you do so. The reality is that as residents patients are scheduled or put on you too quickly for you to spend this sort of quality time regardless.

It's most time efficient not to ask patients questions, but have the note written before you even walk in the room. I was told as an intern that I should be aiming for level 5 consult notes every time, and that's what I did. So I would always get in and out of a room quickly and then write a note. With EMR, writing notes was supposed to be easier, but instead the notes are just lengthier, better written (better for malpractice in some ways), and generate higher billing. With EMR, the charting requirements just get higher, so while the efficiency for doing the same work improves, the bureaucracy increases with this efficiency so that there is no net gain. Not to mention all the headaches with the EMRs when they don't do what you want them to.

If you increase time in the hospital or bring in more residents, none of this will change. Spending more time in the hospital would simply mean being given more patient responsibilities that are the same (i.e. covering another service or more patients per resident). If there are more residents, that just means more services or patients can be covered.

The real way to fix the problem is to incentivize actually spending time with patients. It pays much better to see patients quickly than to see one patient for a long amount of time. It pays much better to write lengthy notes than short ones, regardless of how much time you actually spent with the patient. Residents allow attendings to see more patients and write better notes. This may translate to more time the attending spends with the patient or more time for the attending to do research. It may translate into better attending happiness and recruitment. But, the resident's primary job as a revenue generator by seeing patients quickly and writing lengthy notes is unaffected by anything proposed in that article.

Excellent post. Unfortunately, the hospitals have us (physicians) divided and distracted. It's almost embarrassing to continue arguing that 80+ hours in the hospital is necessary for education and patient safety. Yet, pieces like this (which is in line with all of Pauline Chen's editorials), try to make people believe otherwise.

 

[dragonfly99]

getting 8-15 minutes per patient is not going to end with residency.
We just had a staff meeting where new patient templates were unveiled for outpatient clinic visits - for internal med and cardiology, they want 15 minutes for old patients and 30 min for new patients. For the pediatricians, they want 10 min for old patients and 20 for new patients. This may work for uncomplicated patients but does not really allow time for note writing, entering/typing the patient's list of 15-20 meds into the EMR (since our clinic/hospital system will not pay for RN's or LVN's and our MA's are not allowed to enter any meds or do med reconciliation with the patient). So have to do most of the charting/note writing @the end of the day.
Using premade templates helps, but not that much...
I agree with neuronix's comments and others above...the problem is that the ppl making decisions about what is going to happen with health care are, for the most part, not RN's MD's, DO's, physical therapists, etc. We have a lot of business people, computer people, health care administration trained people, etc., who are deciding how patient care should be structured, and ultimately that is not going to produce optimal medical care. What patients really want and can benefit from is our time and care. What we actually end up doing is either spending the time we need, and then getting frustrated b/c we have to spend hours in the evening and/or weekends working on charting, or run the patients through like it is some fast food joint. And IMHO a lot of the EMR-generated notes are complete crap-ola.