Time Thieves

man-95720_640As I look to the end of my sixth decade, time is more precious than ever. Having a mother, maternal uncle and maternal grandmother with late onset dementias forces the realization that not only is my time limited on this earth, but my intellect as well. How can I squeeze the most out of the moments? Like most physicians, in addition to my career in medicine there are life enhancing avocations I enjoy such as perfecting my French language skills and improving my sketch art that has joyfully crept into my journals. To those ends I listen to Johan, the creator of Français Authentique and began an online course with Sketchbook Skool. Understanding that exercise is the single most important way to ward off memory loss, time must be found to keep moving. Important relationships are built and remain strong with convivial meals and moments together.

My home

My home

Age forces the recognition that time is the true currency of our lives. When people waste it for you, it is frustrating and angst producing. One of the underlying tragedies of physicians’ daily lives, especially in primary care, is the theft of our time, stolen away by the health care system. We entered medicine expecting to spend our lives caring for patients by spending time with them and researching best practices, not being glorified data-entry clerks and insurance company proxies. The amount of time that governmental regulations, employers, compliance directed mandates, insurance company prior authorizations and administrator volume expectations take from us is demoralizing. I want that time back to spend with my patients, my family, and myself.

After more than two years of listening to the innovative suggestions of individuals who care about creative disruption in medicine, I firmly believe that this time theft can only be stopped when our patients come first–before profits, shareholders, meetings, EHRs, or any other thing on the long list of healthcare “needs” that may serve but should not be served. When patient needs are met, so will my own.


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Patient Portal Success

“Doctor Nieder, my wife got this new smartphone and she wants to know why she can’t communicate with you using it. Can she?” This coming from a 70 something patient. I’d seen his wife a few days previously and she had a question about her medication. She wanted to know why she couldn’t just email me about it.

We talked a little bit about the insecurity of email and personal health information (PHI in my world). Then I happily explained that,  indeed she could communicate directly with me using her smartphone. I gave him my card with the RelayHealth information on it, directed him to look to the upper right-hand corner of the website and click “register”. This will take her to this page:

Relay Health Sign in


After finishing the registration process, pick a provider – me – and then RelayHealth sends me notification of the registration. After that she can directly communicate with me. He left the office happy to have good news for his wife.

I know many of my colleagues are hesitant to give patients direct access but consistently the portal has saved me more time than cost me. Patients ask thoughtful appropriate questions. If an appointment is needed a staff member calls them. Otherwise I can give an equally thoughtful response on my own time. As they say “It’s a win-win.”


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Mission Accomplished

Mrs. Smith is adamant, “That amlodipine is making me tired! I can’t take it.” Ms. Smith is 86 years old and her blood pressure is reaching a systolic of 200. She’s still mentally alert and volunteers at a local hospital every week, drives herself to places nearby and lives alone. It is scaring me because I don’t want her to stroke. This is the third BP med she has rejected in as many months. I’ve checked for other causes but think her age is just catching up to her.  Previously she has had a systolic in the 150’s and several years ago we tried several meds, all of which she refused to take. I gave up then but now I’m much more concerned. She has no family to speak of…we go over the pros and cons of the medication. She reluctantly agrees that if she dies from a stroke that would be fine but being in a nursing home unable to talk or walk would be horrible. She will try the medication for another month. “But doctor if I can’t do the things I want to do, I am not going to keep taking it!” She agrees to try it and surprises me with a hug as she walks out the door. “It’s OK Dr. Nieder, I’m not going to live forever.”

Tim Jones slammed his finger in a door and sees the hand doctor on Monday for a non-displaced fracture of his little finger. He wants to ride this weekend in a 100 mile bike ride for some charity or other. “Honestly, what is the risk?” We discuss the fact that the ride itself could cause swelling of the fingers and lots of pain, not to mention if he falls and hits it. “They splinted it really well at the immediate care center. I promise not to take too much ibuprofen.” I give my blessing and hope he is safe.

Mary White arrives, late as usual. My staff is used to that, so they try to schedule her at the end of the day. She has a short litany of minor issues, brings me up to speed on her minor medical problems with specialists, has her yearly exam, we discuss her perfect blood chemistries and she is out the door. 

After 25 years, my patients have me well-trained. And vice-versa–they only call me at night with true emergencies and they apologize when they wake me, they rarely call for last minute refills because they forgot, they bring their meds with them when they come for an appointment and they arrive on time because I’m on time (well, at least I was until Electronic Health Records began three weeks ago). Reflecting on my practice it occurs to me that this is what I hoped my patient relationships would be like at this point in my professional life. 

Mission accomplished. Wonder what comes next?

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Burning Out on Friday Afternoon

Recently a Mayo Clinic sponsored study reported that the rate of physician burnout was much higher than other careers in the US[1], especially among front-line specialties like Family Medicine. This Friday afternoon in preparation to seeing my last patient it hit me “Is this sensation burnout?” Inwardly groaning–a new middle-aged woman with obesity and several psychiatric meds, my thoughts ran to “Who put her on my schedule damn it. It’s Friday afternoon. What did they think they were doing? Doesn’t anyone care about MY needs when they’re scheduling” or words to that effect. For a few moments I pondered my office life.

Lately, my office looks cleaner, because EHR (electronic health records) hides the mass of unfinished charts instead of having them all stacked on my desk. Now there is no obvious sign of all the work I do–no notice to my employer that I am an important, busy and valuable doctor. Despite the reduction in mess, I rarely leave the office before 7, often am there until 9 and everyone keeps telling me that it will get better, since we’re only four weeks “in”. This is exhausting me but at least my husband frequently meets me at the door with a glass of wine in hand. For this I am grateful since sometimes I finish up my charts on-line from  the couch.

Then there’s House Bill 1, the irritating and unfriendly-to-patient-care narcotic bill that takes up extra time and deprives my patients of therapeutic medications and remains a thorn in my side.

Add to those aggravations the everyday frustrations of practicing medicine in today’s fragmented healthcare system and maybe I needed to worry. This line of thought hit me as  I took a big breath, walking in the door expecting the worst and spent the next thirty minutes with a delightful woman who was already taking steps to improve her health. She was working with a trainer, she’d already started losing about twenty pounds. She was upbeat and interesting and I walked out of that room energized.

This Friday I got lucky. Maybe next Friday I’ll be drained. Reflecting on the end of my day I realized that’s just how the rhythm flows in Family Medicine. Like most professions, some days are better than others, but looking at the averages, my curve is mostly on the up. I still like what I do.

1. Shanafelt, Tait D. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. August 20, 2012. http://www.webcitation.org/6AtdqOc4p

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Medical Testing in the Era of Insurance Certification

This morning I started out writing an entirely different blog post but decided to go another route after a painful episode with an insurance company, namely United Healthcare. Why yes, if you read my blogs, this is the same insurance company that denied my patient an antidepressant medication that is the only one in its class. This is the company I tried without success to discuss their rationale with a medical director. However, today was a radiologic procedure I wanted on a patient and was subsequently “invited” to talk to one of their physicians to get approval for it. Does this strike anyone else as odd that I can be essentially “ordered” to talk to one of their doctors but none of them will return the courtesy of my phone calls?

In the last six months medical insurance companies have become increasingly resistant to allowing physicians to order certain studies without certification by them. If you insist that the patient needs the test, then you must have a “peer-to-peer” review in which justification of your need for the test must be made to one of the company’s physicians.

As documented in many studies, there are a lot of unnecessary tests that we physicians order for a variety of reasons. Those include liability concerns, patient requests, and concern that you might be missing a rare disease process. Recently the Foundation of the American Board of Internal Medicine developed recommendations from several medical specialty groups regarding tests or treatments which doctors should question the necessity of before ordering, in a document called Choosing Wisely.

I absolutely agree that we, as a healthcare system, are ordering too many tests. The insurance companies way of dealing with the problem is to have a majority of tests, particularly expensive ones, “certified” before they will agree to pay for them. Today I had two of them that apparently did not fit someone’s algorithm and needed a “peer-to-peer” discussion. Sighing, I called the number listed on the fax paper request from United Healthcare. Dutifully I hit #4 as instructed. This didn’t work immediately because a 30 second introduction had to be finished before option “4” could be chosen. Finally I got through and was instructed to key in the case number. Twelve numbers later, it repeated the number back to me and told me to press “1” if that was correct. Then I got a real person. Up to this point I was OK with how much time I had wasted but the real person on the line was not a doctor. It was someone who wanted to know if I was a doctor and if the patient’s name was so-in-so and if the procedure ordered was a such-in-such. Affirming that was the case I was put on hold. About five minutes later I began to seethe.

Have you heard how primary care physicians are inundated with patients, how we don’t have time see the patients that we have much less makes sure all our refills are done, referrals letters read, referral letters sent, prescription prior authorizations done, patient lab work reviewed as well as keep up with CME (continuing medical education–you want me up-to-date, right?), patient emails, and any other business of healthcare? Every afternoon there are a minimum of 75 charts to be gone through, lots more on Thursdays (because I take off on Wednesday) and Mondays look like a truck backed into my office and dumped the charts onto the desk, chairs and credenza. Don’t even make me think about when I come back after vacation. Well, apparently United Healthcare thinks responsible patient care involves me sitting and waiting on a phone for one of the “peers” to pick it up and determine if my ordering is within their guidelines. This is not something I’m willing to do–so my question to my audience is–should I be willing to? Is this now another part of my job and is it a reasonable thing? Please input, I’d love to hear. 

Please remember that the opinions written in this blog are entirely my own.

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I’ve got some bad news and some good news

That’s the old joke, right? “I’ve got good news and bad news-the bad news is that you have Alzheimer’s. That good news is that you’re going to meet lots of new people.” Unfortunately telling people bad news is no joke and I mused on the experience today as I read an oncologist letter to me regarding one of my patients with a terminal cancer. How do you do that day in and day out? This morning I had to tell a patient, a former smoker, that his chest xray was abnormal and he needs further tests. I’ve known this patient for years and am worried about him. Maybe it will turn out OK…maybe not.

The fact that it bothers me is a good thing. It reassures me that patients’ concerns remain foremost in my practice of medicine. I notice when it’s time for a vacation or at least a few days break from my office, that one of the first things I lose is empathy. When a patient comes in with a problem that seems simple and unnecessary for a doctor’s visit, if my first reaction is “this guy’s wasting my time” I have to stop and think “why do I feel that way?” Usually it has nothing to do with the patient and everything to do with me–worried about my daughter who is working in a third world country, worried about my mom’s forgetfulness and is it something more insidious, etc.

It is curious to see how individuals react to a life-threatening illness. Most of them have such dignity. Often it is the family members whose behaviors become difficult, which in turn makes the emotional turmoil to a patient worse. I remember memorizing Kubler-Ross’s Stages of Grief in medical school. I have been amazed at how much that optional course has enabled me to help patients and their families by better understanding what they are going through. Although things are improving immensely, with programs like Baptist East’s Cancer Resource Center and Friend4Life as well as specific coordinated care centers for certain cancers, the system is still difficult to navigate.  

Often, once a patient begins the work of honing down the diagnosis and determining the treatment of their life-threatening illness, the primary-care physician loses contact with him/her. If my patient is constantly in other doctor’s offices, undergoing uncomfortable procedures and treatment, it is hard for me to add the burden of another doctor’s visit. This is where I see social media as an exciting place for improving care and remaining in contact with my patients. It would be easy to check-in with patients privately on a business Facebook page (which I don’t have yet) or send  private tweets on how they are doing (once all the HIPAA compliant rules are in place). Even now they can send me a secure email private message. These channels would help me to identify when I might need to step in, give advice or just more support. The future is here and I’d like to embrace it. Family physicians have been giving patients bad news for a couple of hundred years. But only in the recent past have we stopped walking their journey with them. I don’t think that’s good medicine, for the patient or for me.

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Specialist versus Primary Care

This morning a patient calls the office stating that his surgeon, who has been treating him for an abdominal wound that is still not closed, told him at his followup appointment that he needs to see a wound care specialist. The patient was instructed to call his primary care physician (PCP) and tell me to set that referral up for him. WHAT?!?!?!?! A few hours later my 28-year-old new patient tells me the orthopedist she saw this morning told her she had a kneecap problem, take Advil, stop running and get an MRI. When the patient explained that she wants to be an Air Force nurse and will have to go through boot camp, it was reiterated that she needs to stop running and maybe she broke her kneecap, so she should wait for the MRI. She has NOT had an injury and  BOTH knees hurt. She has noticed that after exercise her knees feel better. I spent five minutes explaining what patellofemoral syndrome is and suggested that she delay the MRI and see what routine quadriceps exercises do to improve her pain. I suggested substituting bike riding for the running but if running doesn’t seem to bother them, then she might just cut back on that and substitute biking. WHAT?!?!?!?!

This is not an uncommon experience for me. The first episode made my blood boil. AT LEAST once per week, many times more often, specialists tell patients that I will set up appointments, refill medications or interpret the tests that THEY did on a patient. If this occurs following a phone call to me BY THE PHYSICIAN HIMSELF, this is appropriate. But making the patient the intermediary is unfair to the patient, boldly rude to me and in a patient-centered environment, absolutely terrible care.

It is ironic to me that the individual who makes the least amount of money per patient in the doctor hierarchy, is more and more forced into the position of spending more time with patients to make up for, or frequently do, the job of the specialist. I love taking care of patients but I will NOT be used and abused by individuals who, whether they recognize it or not, are treating me like some sort of glorified physician-extender. 

Now I realize that the counter-reaction from the specialists is going to be that we, the first-line doctors, are sending patients to them without adequately working up the problem thus earning the label of “lazy intellect” from the specialist. I truly try not to do that. After all, that is the most interesting part of being a physician, the detective aspect of putting symptoms and tests together to try to make a diagnosis. That is one of the reasons I chose primary care. And most specialists are not egregiously forgetting their own responsibilities. But as it gets harder and harder to navigate the insurance traps and pharmacy coverage nightmares, as specialists accounts receivables fall and they try to increase their patient load to keep up (PCP’s gave up on that a long time ago, we just decided to become employed in droves), it gets easier to tell the patient to call me with the expectation that I’ll take care of it.

“The good physician treats the disease; the great physician treats the patient who has the disease.” William Osler. I would add to that “The good physician sends written communication to colleagues. The great physician picks up the phone to communicate with colleagues.”

OH, and while I’m on the subject of phone communication–does ANY specialist out there remember the common courtesy rules of making phone calls? If YOU want to talk to me, then YOU call me. You do not have your nurse call me and leave me sitting on the phone fuming while I await your presence. Why in the world do you think your time is more important than mine? I mean besides the fact that you get paid thousands of dollars more than I do. Your mother would be ashamed!

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