How do you deal with the paperwork in family medicine/primary care

[luckylotus]

Hi guys,
I am a 3rd year med student who really likes outpatient medicine, and is highly considering family medicine. What gets me down is hearing the huge amount of paperwork that is somehow more unique to primary care. However, there may be hope as I hear conflicting things on the amount of bureaucracy/paperwork/pre-authorizations/ traditional primary care jobs have (not DPC, solo practice, concierge medicine) on this thread.

Some have mentioned that they only spend 30 mins after the office is closed on paperwork and never bring home any paperwork, while others have said that they spend 3 hours or more each day after hours. Given that dealing with paperwork seems to be the root of burnout in primary care, I would like to know if there are currently solutions out there so that I at least have the hope of looking forward to a fulfilling career focusing mainly on my patients. I'd like to work hard during the 8-5pm office hours, be efficient with documentation, but then not take home work with me/ to spend that time with family. Thus, I wanted to get a realistic idea of what I will be faced with and if it's possible (without waiting for the healthcare system to change) to get paperwork done in less than an hour each day before leaving the office, and if so, HOW.

Would like to hear from current practicing family physicians in different models (traditional 8-5 outpatient only vs academic teaching vs inpatient & outpatient). I know that urgent care doesn't have any paperwork haha
1) How many hours OUTSIDE OF WORKING HOURS DAILY you spend on paperwork including charting, phone calls, pre-authorizations, billing
2) How many patients you see on an average day and in what kind of model/setting
3) What solutions do you have to cut down on this time (do you use a dictation system like Dragon? Create templates in EHR? A in-person scribe? A remote google glasses scribe?)
4) is it difficult to find practices where there are people (like medical assistants? pharmacists?) who do some of the paperwork (billing/ pre-authorizations) so that it lessens the burden on you? What do you look for in job offers (ie support staff? did you ask about these things when you considered your job?)

Thank you so much!!

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[VA Hopeful Dr]

1) Zero hours. That said I often work at my desk while eating lunch.
2) 10-16, employer clinic
3) My staff fills out everything on forms, I just sign. They have my signature on a stamp so for lots of stuff they can just stamp.
4) It shouldn't be.

 

[cabinbuilder]

You should have staff that does most of the paperwork for you. You should have a prior-auth person - the doctor doesn't do that (unless its a doc to doc phone call that's required).

Even when I did family practice I never took paperwork home. The key is to look at labs and take care of things as they are resulted so you don't have a huge pile. My nurse called results.

I don't take lunch when the staff does and catch up on things then.
If you have a good EMR, much of the documentation can be built in (the negatives in ROS and PE). We use EPIC in urgent care. I see 45-55 people every day in 12 hours and spend approx. 4 minutes per chart.

 

[luckylotus]

1) Zero hours. That said I often work at my desk while eating lunch.
2) 10-16, employer clinic
3) My staff fills out everything on forms, I just sign. They have my signature on a stamp so for lots of stuff they can just stamp.
4) It shouldn't be.

Thanks @VA Hopeful Dr! Wow, that is so different from what I keep hearing/reading and even observing on my fam med rotation. I am with a solo practitioner whose clinic day ended at 4pm, but I was still in her office helping her click through things in the EHR at 6pm... I don't get to see all the forces that go into this, so I don't know if it's just because she hasn't assigned things to her staff or if she's just not as efficient at documenting as she could be.

So do you believe the 'primary care physicians are drowning in paperwork' and 'having to fight with insurance companies' idea that gets perpetuated to medical students is largely a myth? I have been trying to do my own research on this and it seems like on many sites including the AAFP where there are also physicians who attest to doing hours of paperwork after office closure and more importantly, wanting to quit practicing all together because of the bureaucracy. Its just hard to tell if these people who complain are in the minority or the majority of primary care experiences.

Do you document while talking to your patients in the exam room then? And then spend like 5 mins on a chart after the visit is over? What things are done by your staff vs things that you the physician must do and cannot delegate out? (so you're not doing the coding or billing?).

So would you say your workday is fulfilling in that you get to focus your attention on the patients and on medicine without the administrative stress overshadowing everything you do, and that you have a great work-life balance given when you leave the office, you are truly done?

 

[luckylotus]

You should have staff that does most of the paperwork for you. You should have a prior-auth person - the doctor doesn't do that (unless its a doc to doc phone call that's required).

Even when I did family practice I never took paperwork home. The key is to look at labs and take care of things as they are resulted so you don't have a huge pile. My nurse called results.

I don't take lunch when the staff does and catch up on things then.
If you have a good EMR, much of the documentation can be built in (the negatives in ROS and PE). We use EPIC in urgent care. I see 45-55 people every day in 12 hours and spend approx. 4 minutes per chart.

Thanks for your response @cabinbuilder! So would you say that the physicians who are complaining about the strain of doing paperwork that is taking away from the care they could be giving their patients is largely a result of not having the right staff to help out and it's not really inherent to being a primary care physician? Do you feel like you have an appropriate amount of autonomy at work and can do what you believe is best for the patient without being restricted by policies out of your control? Do you feel like you have enough time with family, travel, and other hobbies?

This is literally my main concern about primary care. I love being able to know the whole family over time, the variety, and being the first to try to figure out diagnoses. I also liked the normal hours, stability, and ability to have a life outside of work that family medicine allows. I know that most outpatient jobs are 40 hours of PAID TIME, but I don't know how much time the average primary care physician is spending on work related things outside of the office hours. I have this projected fear that the stress and strain of keeping up with all the rules and regulations of insurance policies or billing (that other specialties don't have to deal with to this extent), loss of autonomy, and taking out personal family time constantly to do unpaid work that does not directly help patient care would slowly erode at my ability for compassion b/c I would hate going to work. I just don't know how much of this fear is based in reality vs just biased views from online articles, other specialists who don't really know what they're talking about, and my limited experiences shadowing family physicians. I would have hated to choose another specialty over family medicine only because of my misguided belief that I would have more control and work-life balance. Thank you for calming my fears and making me feel more confident that I could be a happy family physician who feels that I have the ability to do the best for my patients and also be there for my family after work. That is all I could ask for in a career.

 

[deleted87716]

I’m not sure where you got the idea that other specialties don’t have to deal with paperwork or insurance hassles, but you’ve been misinformed. The hassles may be slightly different (ask any specialist who works in the hospital about the stuff they have to deal with), but it’s just part of being a doctor. You can either be efficient about how you handle it, or you can let it bury you. It’s up to you.

 

[cabinbuilder]

All specialties have paperwork. I don't do family practice anymore and do strictly urgent care. My base is 10 days a month but I still do locums on the side when it suits me as I get restless. I feel I have more autonomy in urgent care as I never got into the right practice that didn't have overbearing admin an I got tired of quitting and having to start over.

With that being said, there are still labs in urgent care and patient's calling wanting work extension notes, pharmacy changes, med reactions and want something different, etc; etc. etc. You will not get away from it. You have to learn to manage it.

Since when do you learn the rules of insurances? Never. You have staff for that. You should know how to do your own billing/coding so you can maximize your return but there should always be a biller/coder who is looking over the final charges.

I think your fears are unfounded and most I know get their stuff done and live their lives with the shifts are over.

 

[VA Hopeful Dr]

Thanks @VA Hopeful Dr! Wow, that is so different from what I keep hearing/reading and even observing on my fam med rotation. I am with a solo practitioner whose clinic day ended at 4pm, but I was still in her office helping her click through things in the EHR at 6pm... I don't get to see all the forces that go into this, so I don't know if it's just because she hasn't assigned things to her staff or if she's just not as efficient at documenting as she could be.

So do you believe the 'primary care physicians are drowning in paperwork' and 'having to fight with insurance companies' idea that gets perpetuated to medical students is largely a myth? I have been trying to do my own research on this and it seems like on many sites including the AAFP where there are also physicians who attest to doing hours of paperwork after office closure and more importantly, wanting to quit practicing all together because of the bureaucracy. Its just hard to tell if these people who complain are in the minority or the majority of primary care experiences.

Do you document while talking to your patients in the exam room then? And then spend like 5 mins on a chart after the visit is over? What things are done by your staff vs things that you the physician must do and cannot delegate out? (so you're not doing the coding or billing?).

So would you say your workday is fulfilling in that you get to focus your attention on the patients and on medicine without the administrative stress overshadowing everything you do, and that you have a great work-life balance given when you leave the office, you are truly done?

Its not a myth, but if you set things up correctly then you won't have a big problem with it.

For instance - PAs for drugs. Many, if not most, EMRs these days have insurance formularies built in. You can avoid 95% of prior auths by picking the drug the company is OK with you using. The want humalog when I originally wrote novolog? Fine by me. Also generics as often as possible.

If an MRI gets denied or needs a PA that I can't just sign, patient gets a referral to ortho. They get denied less often than us primary care folks do.

I rarely document in the room. Lots of people do and that's fine but I don't like not focusing entirely on the patient. That might change, but its not a big deal either way.

Solo practitioners like the one you describe also have to deal with running the business part - payroll, taxes, compliance, and so on. That is something of a headache as I've been there before.

Long story short: paperwork is irritating at most to me and I still enjoy what I do most days.

 

[TableMD]

Tasks for staff
Decisions for physicians
- an attending

 

[PlutoBoy]

Hi guys,
I am a 3rd year med student who really likes outpatient medicine, and is highly considering family medicine. What gets me down is hearing the huge amount of paperwork that is somehow more unique to primary care. However, there may be hope as I hear conflicting things on the amount of bureaucracy/paperwork/pre-authorizations/ traditional primary care jobs have (not DPC, solo practice, concierge medicine) on this thread.

Some have mentioned that they only spend 30 mins after the office is closed on paperwork and never bring home any paperwork, while others have said that they spend 3 hours or more each day after hours. Given that dealing with paperwork seems to be the root of burnout in primary care, I would like to know if there are currently solutions out there so that I at least have the hope of looking forward to a fulfilling career focusing mainly on my patients. I'd like to work hard during the 8-5pm office hours, be efficient with documentation, but then not take home work with me/ to spend that time with family. Thus, I wanted to get a realistic idea of what I will be faced with and if it's possible (without waiting for the healthcare system to change) to get paperwork done in less than an hour each day before leaving the office, and if so, HOW.

Would like to hear from current practicing family physicians in different models (traditional 8-5 outpatient only vs academic teaching vs inpatient & outpatient). I know that urgent care doesn't have any paperwork haha
1) How many hours OUTSIDE OF WORKING HOURS DAILY you spend on paperwork including charting, phone calls, pre-authorizations, billing
2) How many patients you see on an average day and in what kind of model/setting
3) What solutions do you have to cut down on this time (do you use a dictation system like Dragon? Create templates in EHR? A in-person scribe? A remote google glasses scribe?)
4) is it difficult to find practices where there are people (like medical assistants? pharmacists?) who do some of the paperwork (billing/ pre-authorizations) so that it lessens the burden on you? What do you look for in job offers (ie support staff? did you ask about these things when you considered your job?)

Thank you so much!!

I really don't think that we do as much paperwork as people think. I'm not filling out FMLAs on a daily basis. Most of my paperwork is charting my patient interactions.

I think primary care is a lifestyle specialty. I work from 8:00 AM to 4:30 PM, with a two hour break (from 11:00 AM to 1:00 PM). I have six weeks of paid time off.

1) Less than one
2) About 20
3) I don't think I could cut down on it
4) I don't do preauthorizations and rarely have to deal with peer to peer reviews of my orders. I have staff to do that for me.

 

[PlutoBoy]

So do you believe the 'primary care physicians are drowning in paperwork' and 'having to fight with insurance companies' idea that gets perpetuated to medical students is largely a myth?

Do you document while talking to your patients in the exam room then? And then spend like 5 mins on a chart after the visit is over?

So would you say your workday is fulfilling in that you get to focus your attention on the patients and on medicine without the administrative stress overshadowing everything you do, and that you have a great work-life balance given when you leave the office, you are truly done?

1) I don't think so. It's a myth.
2) Yes. I document while in the room.
3) Yes.

 

[s109442]

You should have staff that does most of the paperwork for you. You should have a prior-auth person - the doctor doesn't do that (unless its a doc to doc phone call that's required).

Even when I did family practice I never took paperwork home. The key is to look at labs and take care of things as they are resulted so you don't have a huge pile. My nurse called results.

I don't take lunch when the staff does and catch up on things then.
If you have a good EMR, much of the documentation can be built in (the negatives in ROS and PE). We use EPIC in urgent care. I see 45-55 people every day in 12 hours and spend approx. 4 minutes per chart.

How much do you make per hour seeing that kind of volume?

 

[DoubleBogey]

If pts needs FMLA filled out - I have them make an appt and then fill it out at the office visit. Agree with sentiments above - tackle the lab results and messages as they come so you don’t take that stuff home with you.

 

[deleted87716]

I've never understood why people hate FMLA forms so much. Sure, they're mildly annoying, but they're easy to fill out, and you can always charge a form fee.

 

[PlutoBoy]

I've never understood why people hate FMLA forms so much. Sure, they're mildly annoying, but they're easy to fill out, and you can always charge a form fee.

We charge $25 but I end up doing it for free quite often. If a patient brings it to one appointment I fill it out on the spot.

 

[cabinbuilder]

How much do you make per hour seeing that kind of volume?

I'm salary with quarterly incentive & RVU bonus. When I do extra shifts outside my 10/month I get $115/hr and the RVU's are counted in the total.

 

[AFamilyDoctor]

I really don't think that we do as much paperwork as people think. I'm not filling out FMLAs on a daily basis. Most of my paperwork is charting my patient interactions.

I think primary care is a lifestyle specialty. I work from 8:00 AM to 4:30 PM, with a two hour break (from 11:00 AM to 1:00 PM). I have six weeks of paid time off.

1) Less than one
2) About 20
3) I don't think I could cut down on it
4) I don't do preauthorizations and rarely have to deal with peer to peer reviews of my orders. I have staff to do that for me.

But how much are you getting paid?

 

[PlutoBoy]

But how much are you getting paid?

Less than $500,000, more than $100,000.

 

[AFamilyDoctor]

Less than $500,000, more than $100,000.

Doesn't help much...

 

[VA Hopeful Dr]

Doesn't help much...

That is a fairly rude question...

 

[luckylotus]

I really don't think that we do as much paperwork as people think. I'm not filling out FMLAs on a daily basis. Most of my paperwork is charting my patient interactions.

I think primary care is a lifestyle specialty. I work from 8:00 AM to 4:30 PM, with a two hour break (from 11:00 AM to 1:00 PM). I have six weeks of paid time off.

1) Less than one
2) About 20
3) I don't think I could cut down on it
4) I don't do preauthorizations and rarely have to deal with peer to peer reviews of my orders. I have staff to do that for me.

Nice! What is the setting you work in: multi specialty vs single specialty with multiple fm/im docs? Rural or urban?

 

[PlutoBoy]

Nice! What is the setting you work in: multi specialty vs single specialty with multiple fm/im docs? Rural or urban?

Urban. Single specialty with multiple docs/midlevels.

 

[luckylotus]

I’m not sure where you got the idea that other specialties don’t have to deal with paperwork or insurance hassles, but you’ve been misinformed. The hassles may be slightly different (ask any specialist who works in the hospital about the stuff they have to deal with), but it’s just part of being a doctor. You can either be efficient about how you handle it, or you can let it bury you. It’s up to you.

For those who wonder where I got the idea from, it's the stuff that I've heard in my 3rd year from other physicians in the hospital say as a reason not to go into primary care, as if it's a lot worse for primary care than the specialists. As I mentioned, I don't know how much truth there is to it, but when I was trying to do my own research on this to get other opinions, I kept running into article after article on primary care and burnout mainly linked to doing unpaid work/work outside of normal hours that included both things that directly linked to patient care (ie reviewing labs and notes from specialists), but also other administrative tasks (documenting, check boxing quality measures) that does NOT directly improve patient care.

Articles such as "This dirty secret keeps doctors from doing their job" on kevinmd
(SDN won't allow me to post any links right now...)
saying "The dirty little secret we all deal with in primary care is this: We make our doctors, PAs and NPs see as many patients as they possibly can, with ever-increasing demands on the complexity of care they deliver, and on the comprehensiveness of their documentation and quality reporting. Then, we quietly assume they will be able to do all this extra, unscheduled and uncompensated work without falling behind, making medical mistakes or simply burning out."

Now, doctors are working just as hard taking care of patients in the office, but they are also expected to — on their own time — handle all sorts of ongoing hand-holding between visits. This happens through phone calls, electronic messaging and reading and commenting on endless streams of reports from case managers, specialists, hospitals, emergency rooms, walk-in clinics, pharmacy benefit managers, insurance companies and medical supply companies."

So I was reading about all these articles, but I just didn't know if this was the case for the MAJORITY OF/AVERAGE primary care physicians, or only the ones who were in special situations (ie being the sole country doctor or working in an understaffed clinic or working under a terrible administration). If this kind of extra burden was inherent to primary care and most docs can't escape it, then that would likely deter me from entering the field. But, if I know that I can have staff to help to deal with a lot of these things that's causing physician burnout, then I know that it's just up to me to find the right kind of practice. That's what I mainly wanted to tease apart. I think, based on what you guys are saying, is that it's really up to the individual to find the right type of supportive practice that allows the physician to not have to do very much work outside of working hours by delegating most tasks to non-physician workers.

But in the end, I really like the idea of primary care, of getting to know whole families and focusing on prevention as well as diagnosing things, the variety, and just having that long term relationship, that I probably would still go into it knowing all the things primary care physicians have to put up with....but it really is reassuring to hear that it's POSSIBLE to go home on time after work while still being a good doc to your patients

 

[deleted87716]

Like most jobs, a lot of this stuff depends on who you work for. Medicine is no exception. Choose wisely.

 

[Keona]

Another thing to consider is that right now she's working with a student. Students slow us down quite a bit. (I'm a resident, but having them present and teaching takes time out of my day). If she says her time is usually just at the office and not too late I'd believe her. I like to go into clinic early to finish and review labs from the day before, return phone calls, etc. I don't leave in the evenings until I finish my notes so that when I am home I can be home with my family and not have work taking over every aspect of my life. This may change in the future as i'll have a shorter commute and might want to go home and finish notes after I finish with kids for the night. I'm going to an outpatient only practice with great support available. The other doctors leave during the day between 4-6, work 4 days a week. Pay is competitive for family medicine in the area. It's hard to tell amounts without having COL accounted for, but I will be comfortable after graduation with paying loans and a mortgage.

We work with other specialties frequently and many of them are not finishing notes or paperwork during the day. It's very person dependent. Many clinics don't open until 8:30 or 9, so if you get there at 8 you could likely do most of the paperwork and any additional charting needed for the patients.