I don't have enough time, do you?

Discussion in 'Pain Medicine' started by epidural man, May 17, 2014.

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  1. epidural man

    epidural man ASA Member 7+ Year Member

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    Luckily, my practice allows me 45 minutes for a new patient.

    But I don't think it is NEAR enough time.

    In my mind, to be a great doctor for these deserving patients, minimum, I need to

    Read old notes, including psychology history, physical therapy progress, etc.
    Review the MRI images (not just read the report, but look at images). Typically I look at T2 axial and sagital, then T1 sagital to look at fat around the nerve root in the foramen). I look at other spin seuquences if looking for something special.
    Review and score the patients questionaires (PCL, PHQ9, ODI, PDQ)
    Reveiw old medications including a check on the controlled substance inquiry
    Now, I can finally see the patient.
    1.. Get a history - let them tell the story they want to tell. I often direct and cut them off, which is not good doctoring, but I don't have time. Get a social history and substance abuse history.
    2. Physical exam - which is usually cursary and not in depth honestly. I should do a much better job, but again, I need to move.
    3. show the MRI images to the patient. It always blows me away that this is the first time any one has EVER shown the images to the patient and explained the results and meaning of the images - not what the radiologist wrote.
    4. Spend a GOOD amount of time, explaining pain, how chronic pain exists, about the inhibitory pain system - why yoga, exercise, movement, meditation, etc work, why I want them to see pain pyschology. Then I have to explain how TENS works and why I want them and how I want them to use it.
    5. Explain why opioids don't work in chronic pain and some physiology about all this. Explain why I won't give it to them, or if I am going to, go over the chronic opioid therapy safety program and all the things we will be doing.
    6. Describe in just enough detail about the procedure, if any, we will be doing, what are the options, and why we are doing it and what to expect.

    There probably is a set of ten other things I should do, but don't have the time to. And I have 45 minutes. I think in some private practice models, they have a lot less time. In my training, a PM&R guy would take 90 min with each new patient. I thought that was great.

    What surprises me is I often hear how PP physicians talk about how many patients they can see in one day....like that is a great badge of courage or a sign of skill. In my mind, that only shows you are crappy doctor who doesn't do half the things you are suppose to do. But that's just me.
     
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  3. emd123

    emd123 7+ Year Member

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    Unfortunately in today's world, with reimbursements being cut (all specialties) you have very little time. The primary care guys I work with only give themselves 30 for new and 15 for follow up, and they're responsible for the persons entire health, not just their pain. It's the unfortunate reality of our system, and in private practice, you do what you have to, to survive. Patients love doctors who spend a lot of time with them, and it is good care (if the time is spent efficiently). But unfortunately, lengthy time spent with patients is becoming cost-cut to extinction.

    Good for you that you're able to spend lots of time. My practice is still growing, so I can do that too, but I don't know how long I'll be able to. Enjoy It while you can.
     
  4. Pacman27

    Pacman27 7+ Year Member

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    I am in a similar boat, however I think the key is spending that time on patients that actually care to get better and want to be their own advocate. I can usually figure that out in the first 2 minutes of a conversation. Spending all of that time on your non compliant diabetic who continues to chain smoke maybe is useless
     
  5. Jitter Bug

    Jitter Bug 7+ Year Member

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    I like to tell the story to the patient a chapter at a time. 90 minutes may make you feel thorough but overwhelm your patient. Multiple studies have shown patients only retain a fraction of what you tell them on any given day. So I use the initial visit mostly for me, gathering the info I need to be a good doctor, and limit myself to only a few minutes of educational "teaching" in addition to generating a plan.

    But I reinforce and build on that teaching at every followup appt. Agree with Pacman need to decide early on which patient is just going through the motions and which patient really wants to learn and change to take better care of themselves, and is willing to come in to the office regularly to try new things.
     
  6. lobelsteve

    lobelsteve SDN Lifetime Donor Lifetime Donor 10+ Year Member

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    new patients can be from 10 minutes to an hour. Depends on pathology (Psychology). Acute radic is 10 minutes, golfers spondylosis is 10 min, traumatic SIJ is 10 min. Addict with kicked out of 3 pain clinics with FBSS and abuse issues, 1 hour and no procedures forth coming, money loser, but possible saving a life.
     
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  7. bedrock

    bedrock Member 10+ Year Member

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    How do set up your schedule to account for going from 10 min to an hour on some patients? You wouldn't finish your morning until 2pm if your schedule is wrong.

    Golfers spondylosis? Havent heard that term.
     
  8. knoxdoc

    knoxdoc New Member 10+ Year Member

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    Agree, but I'd add that this advice goes for the doc every bit as much as the patient. I can only absorb a limited amount of info in one visit, so I start with 1-2 major issues or concerns and go from there. 90 minutes would be a complete waste of everyone's time. That's why college lectures only last 50 minutes.
     
  9. clubdeac

    clubdeac 7+ Year Member

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    All I know is that I'm now averaging ~25 patients a day and I'm busting my balls to be thorough and document properly. Any more is too much for this kid
     
  10. emd123

    emd123 7+ Year Member

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    I agree. With a mix of new, and follow up patients, 25 in a day is a solid number. Crossing much beyond that with opiate patients and the necessary monitoring that is involved, gets tough without an extender (which is a whole other can of worms). That assumes an 8 hour day. In a world with malpractice lawyers swarming plus the amount of opiate abuse and DEA regulations we have to deal with, there's definitely a limit to how fast I feel comfortable going, also.

    Only pill mills see 100 patients per day, with lines out their waiting room doors like it's a Beatles concert, circa 1965.
     
    Last edited: May 18, 2014
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  11. hyperalgesia

    hyperalgesia member Lifetime Donor 7+ Year Member

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    I'm not that busy yet so I bill by time. My documentation is concise and I spend a lot of time talking to the pts. I don't document anything that is not relevant. I'm going to miss this...
     
  12. lobelsteve

    lobelsteve SDN Lifetime Donor Lifetime Donor 10+ Year Member

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    Play the odds. Most of my referrals are older folks without as many issues as younger folks with comorbid psych, pain, addiction issues.
    Golfer's with axial back pain worse on their leading side. THey get a new driver every year and swing it 110%. They know how many cc's and talk about carbon fiber, titanium, and the technology as if it will get them on the seniors tour.
     
  13. ziggyziggy

    ziggyziggy 5+ Year Member

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    I spend lot more time on documentation because my charts are the only "witness" for what happened in the room.
     
  14. SSdoc33

    SSdoc33 10+ Year Member

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    90 minutes with a patient? really?

    unless you work at the VA (which i know that you do), 90 minutes/patient, or even 60 for that matter is financially unsustainable.

    you have to balance quality with quantity.

    in the fee-for-service system with very narrow margins, you really do have to work efficiently and quickly if you expect to make any money. or you can do multilevel injections on everything with a pulse.

    single-payer continues to be the best theoretical, yet worst practical option we have.
     
    Last edited: May 19, 2014
  15. emd123

    emd123 7+ Year Member

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    Amen to that.
     
  16. emd123

    emd123 7+ Year Member

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  17. Ducttape

    Ducttape SDN Lifetime Donor Lifetime Donor 5+ Year Member

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    "we" spend 60+ minutes with the patient.

    by that, the midlevel spends roughly 40 minutes, i spend 20 minutes, and the nurses do roughly 10-15 minutes of teaching.

    only in a practice that is not utterly dependent on the time margins do i believe this can be done. it would never work in the PP world.

    of course, the patient population that i am advising require much more, er, encouragement to get activated.
     
  18. ParaVert

    ParaVert Interventional Pain 10+ Year Member

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    Time crunch is a private practice reality. Being the go-to guy in your area for complicated patients is a double-edged sword. Sure, the PCP would send his mother to you. But then again, we're in the business of business.

    Choosing not to accept high complexity / high liability patients may not be the most altruistic move, but it does improve your sanity, schedule, and bottom line. Lawyers choose which cases they take by their likelihood of winning and making a profit. Why should we not take a lesson from them? 90% of my income is easy money from straightforward referrals and B/B procedures. The 10% takes up 50% of my time, mental energy, and liability.

    More and more, I assume the role of the small-town doc.

    Sorry I can't help you, it sounds like you've tried lots of things. I'm not really comfortable prescribing all that medicine, either. I know your doctor is looking for someone to take care of your pain, but I don't have the tools necessary to do that. Let me refer you to the (university, fresh grad down the street, medicaid pill mill, etc), I think you'll be better served there than by what I can do. So sorry to waste your time, but you really need special attention.

    Patient leaves feeling special, not shafted. My head doesn't hurt. The LOL in the next room waiting on her TFESI and tramadol has a jar of home made fig preserves for me.

    We can't help them all. We must protect ourselves first. The more I do this, the happier I am and the better dad and husband I become. Really.
     
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  19. emd123

    emd123 7+ Year Member

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    +1
     
  20. Yo GabbaPentin

    Yo GabbaPentin 5+ Year Member

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    As soon as they develop a billable code for listening to bull$hit, I will be more than happy to sit in a room 90 minutes with my 25 year old patients to listen to how severe their pain is from their hair to toe nails. Up until then, they will get a 5 minute record review, 5 minutes of my listening, 3 minutes of my talking and 2 minutes to get the hell out my office.

    In my limited experience, reviewing the pathology in detail and actual MRI pictures with the patient only produces a blank 1000 yard stare.

    For 95% of my patients, they get the "pain for dummies" version.

    "Yeah, you DO gots the BONE on BONE with da pinched sciatica nerve. What yous needs is some PT. Yeah... I know dat spine shot killed your friends mom, but it done worked good on Joe over there. Schedule up front and ya'll come back now."
     
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  21. bedrock

    bedrock Member 10+ Year Member

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    :rofl:

    Seriously though, what was described by the OP is an academic model for seeing patients in clinic. That worked 25 years ago when insurance actually paid you to do all those things and when patients respected their doctors and accepted what we told them, and didn't just look everything up online and try to "self-diagnose" on their way home from the office, and didn't argue about 80% of the medical advice we offer them.

    When I was a fellow, I spent 50 min with new patients. When I started PP, that switched to 30 min. Now I'm down to 15 min new appts for routine new pt, and 25 min for complicated patients (nurse screens new consults by keywords i gave her to stratify if they get 15 or 25 min).

    Before I see the patient, my MA enters on the computer, everything for a level 4 visit but my description of relevent MRI imaging and the A/P.
    I look at MRI images right before I go in, I don't show or describe the MRI to the patient 99% of the time, because that always adds another 10 min to the consult (FOR WHICH THEIR INSURANCE DOESN'T PAY ME).

    I used to spend lots of time discussing procedure risks, and medication side effects. But that would just get patients overly frightened for their procedure and they would somehow always get one of the rare medication side effects I mentioned. Now I've stopped doing both things, which saved me lots of time. I still review the extremely common procedural issues, as this cuts down on calls, and I review just the 1-2 most common medication side effects, when prescribing meds.

    I'm with yogabba in that I definitely do describe spine issues for dummies as I'm not going to review complex biomechanics with a plumber who has a disc herniation and just needs PT, gabapentin, and his ESI. People always want me to predict the next 20 years of their life, and I now just say, "we'll just have to see how well you do, there is no guarantee with these procedures, however it's much less risky than surgery". After I've said it twice, they get the point and I move on to the next patient.

    Paravert said it well-
    "We can't help them all. We must protect ourselves first. The more I do this, the happier I am and the better dad and husband I become"

    Once I accepted this and changed my practice model, I would actually have some energy at the end of a workday to play tennis with my girlfriend, go out for dinner with my friends, workout, or something similar.
    I still want to help people, but not at the cost of my sanity, my friends/family, or my personal health. I basically gave up all three during med school, residency, and fellowship, but no longer, 13 years was enough and life is short.
     
    Last edited: May 19, 2014
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  22. jonnylingo

    jonnylingo Junior Member 10+ Year Member

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    Everyone's a skeptic. I'm preaching the gospel of lifestyle modification... exercise, stop smoking, get the sugar under control, less pills... everything they don't want to hear.
    And of course there's the belabored conversation:
    "You need to lose weight"
    "But doc, I can't exercise cause I'm in pain"
    "Diet has more to do with weight loss than exercise"
    Patient stares at me in shock "I only eat one piece of dry toast a day"
    Me, wanting to say "Wow, you must be special. The laws of physiology must not apply to you"


    I'm thinking of having my MA input the bulletpoints necessary for a level 4. Thanks bedrock. I'm about to go nuts repeating everything that's on the intake form verbatim.

    Anyone using a scribe?
     
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  23. lobelsteve

    lobelsteve SDN Lifetime Donor Lifetime Donor 10+ Year Member

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    You really need to spend a few more minutes with each patient. Or I will need to break up with your girlfriend.
     
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  24. Ducttape

    Ducttape SDN Lifetime Donor Lifetime Donor 5+ Year Member

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    problem is, where do those other patients go, the high complexity/high liability patients?

    University centers can only take so many, although this is probably the best location for them.


    now,just to combine threads for a minute, imagine if there were no University centers or hospital outpatient departments for them to go, as they have to be profitable too, and as PP/office based practices push to equalize POS. these low lying fruit, as it were, are most likely to abuse drugs, most likely to use illicit drugs (at least, thats my impression), most likely to go on SSD. they also are fairly numerous, possibly 20% of Americans...

    as a private practitioner, that is no skin off of your backs. but from a societal standpoint...
     
  25. lobelsteve

    lobelsteve SDN Lifetime Donor Lifetime Donor 10+ Year Member

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    They go to other pain docs. There is no shortage of Pain Physicians, pain docs, pain providers, and pill mills. We are all the worlds greatest pain doctors, so why should it matter who they see.
     
  26. SSdoc33

    SSdoc33 10+ Year Member

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    yes, it sucks for society. too bad. it is not reasonable for PP to see these mainly medicaid patients and lose money doing so. the PP practitioner did not create a system nor society that does not value time spent with indigent patients. it is not their responsibility to be a slave. the government did not pay for their medical school, nor take their MCATs for them.
     
  27. Ducttape

    Ducttape SDN Lifetime Donor Lifetime Donor 5+ Year Member

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    that was not my point of contention. i agree, it is the PP decision on whether to see medicaid patients. with maybe 1 or 2 exceptions on this board (steve?), i doubt you guys are seeing a significant portion of medicaid. i do, but ive chosen to fight this battle of trying to enable these patients, integrate them back into society, and at least prevent them from killing themselves, others that take their pain pills, and condemning their children to lives of addiction.


    what i am trying to tie together is the fact that these indigent (arent we actually all "indigent"?) patients will need care somewhere, for the better of society as a whole. On the other hand, PP's are pushing hard to eliminate POS differential. if there is no POS differential, i can see noone taking on these difficult patients, much to the detriment of societal balance.


    fyi the government did actually pay for a good portion of everyone' schooling, as almost all ACGME residencies take medicaid funding...
     
  28. SSdoc33

    SSdoc33 10+ Year Member

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    A: residency is not schooling. 50K/year for a doctor is break-even at best.
    B: if POS differential goes away, and goes down for everyone, then you are right. if by some miracle, PP gets reimbursed more equally for medicaid patients, then more of these patients will be seen.
    C: your implication is that if a doc does not see these difficult patients, they are not preventing them from killing themselves and condemning their children. thats a bit of a stretch. dont play the "holier than thou" card.
     
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  29. epidural man

    epidural man ASA Member 7+ Year Member

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    Thanks for the comments. Interesting discussion.

    Obviously, not every patient I see needs the full time - nor does every patient even want to spend that time with me. I have my 10 min in and out as well.

    However, a large majority of my axial mechanical back pain patients are going down the rabbit hole...and to echo Ducttapes sentiment, I feel like if I don't spend the time...NO ONE will. And here is the problem...

    They have a PCP that thinks that the radiologists read means something, and so they tell the patient this. The patient holds on to this desiccated disc and abutment of the S1 nerve root like that is actual pathology. Then they are sent to physical therapy and neurosurgery - thus validating that they have a HUGE problem. The neurosurgeon tells them he has nothing to offer, but that doesn't mean they don't have a problem so they send them to the pain clinic - again - the message is - you have a problem, the medical system has a fix. The majority of physical therapist have NO IDEA how to treat chronic pain, so they get discharged from physical therapy with the language "we have nothing to offer" and the patients hears, "I am so BAD OFF that even the physical therapist can't help me."

    By the time I see them, I see someone with some back pain that has nothing wrong with them - but they see it completely different. In fact, if something isn't done, this will be the patient that spends their life in pain, on the coach, collecting some sort of government payment for their horrible injury.

    I feel compelled to at least TRY to do something. So I have to spend time looking at their psych history. I have to look to see how disabled they feel they are. I have to show the images. I agree that they don't get much of the picture, but when they SEE that the disc isn't bulging, that the nerve is FAR AWAY from the disc, or barely touching it, I think it helps - maybe not, but many of them tell me it does. I need to reassure them that they can MOVE and will be just fine. That they can play tennis, and swim, and they won't snap in half or become paralyzed. I need them to understand that THEY have the power to make themselves better, not my needle.

    This takes a lot of time - and I don't have enough of it.

    And I could just offer them some needles, but that just makes it worse...tell them I have the fix...and when it doesn't work, it validates how horrible their problem is.
     
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  30. lord_jeebus

    lord_jeebus 和魂洋才 SDN Moderator 10+ Year Member

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    I thought CMS required that the physician personally enter the HPI.
     
  31. bedrock

    bedrock Member 10+ Year Member

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    I sign the entire note at once, so the HPI is considered to be mine( I do review the HPI before signing for accuracy).
    This is no different that using a scribe like some physicians do or residents doing a note, that is signed by their attending who charges for that visit.
     
  32. bedrock

    bedrock Member 10+ Year Member

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    I agree with what you're trying to do. This is a valuable clinical service, but it's not valued by the system.

    Definitely agree that it's important to tell these people they have nothing significantly wrong with them, they're safe to move, and need to move to function and feel better.
    Whether they believe you or not after you tell them is another question, and I won't spend an additional 20 minutes trying to convince them. They've received my expert medical opinion, I'm not required to be a martyr to their belief system.
     
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  33. Ducttape

    Ducttape SDN Lifetime Donor Lifetime Donor 5+ Year Member

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    Response:
    A. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=73
    B. this presupposes that PP wants medicaid patients back. from the tenor of most of those posting from the PP world, that is not a given.

    C. my contention is that access to appropriate pain management is essentially closed to these patients, so they recieve their pain care from PCPs, ERs, dentists, etc. almost no patient that i have seen have had a discussion on safekeeping of medication, the risk of exposure of opioids to children, or discussion on how to see warning signs for addiction in family members (esp. kids). PCPs dont have time to do that.
     
  34. PMR2008

    PMR2008 PM&R 7+ Year Member

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    Right out of fellowship I started my own practice. I have kept a very low over head (part time MA, renting space in a primary care office, sharing computers/EMR, using in house billing). I have been very selective with my patients and no one gets opioid. I only accept 2 PPO insurance plans or cash. I started off 1 days a week and expanded quickly to 2 days. It has been 10 months since I started and I am seeing patients 3 days a week.
    I still see new patients for 60 minutes and followups for 30 minutes. Patients love the educational aspect of the visit and I follow all the 6 things epidural man mentioned. Because I am spending extra time with the patient my billing is time based. All the patients get my email address. So far only 25% of patients email me(My MA screens the emails to see if they need medical advice) but I email 100% of them with my weekly newsletter and educational content. Since I have barely done any marketing 100% of my referrals are word of mouth. I believe that the type of service I provide sets me apart and patients are quick to recognize it. Maybe it is because of the wide variety of patient diagnosis I see but i can not imagine seeing 25 patients a day and not missing things.
     
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  35. Ligament

    Ligament Interventional Pain Management Lifetime Donor SDN Advisor 10+ Year Member

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    No, it is the worst theoretical, and worst practical option we have.
     

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