Friday Morning Overload

Somewhere mid-morning on Friday I lost control. Things were perking along very nicely and then suddenly (or so it seemed to me), I was nearly an hour behind. Up until then even my EHR notes were signed at the end of each visit. Perhaps it is my German heritage, but my skin begins to crawl when patients wait more than fifteen minutes. For years it has been a matter of pride that they rarely waited longer than five or ten minutes and frequently they were seen within a minute or two of their appointment time. Nor did patients feel they were getting short shrift from me. My scheduling clerk knew her business and the patients well enough to pad an appointment when necessary. In the last three months that has not been the case. Hopefully this is temporary due to the extra time involved in learning our new documenting system but being behind brought me to a reflection on the importance of timely appointments.

Sometimes, no matter how good my intentions, the cards are stacked against me--Mrs. Jones lost her job and her mother in the same month; Mr. Bausier came in for a cold but just happened to mention the pressure sensation in his chest that seems to be more frequent and is associated with exertion; and in listening to Mrs. Roberts' heart it is obvious that the rhythm is just not right. And all in the same morning. Other times, it's more personal--I'm talking to a patient whose daughter went to high school with mine and we have to catch up or my favorite French national comes in who prefers to tell me her medical problems in her native tongue. Not because it's better for her but she knows I need the practice. 

On Friday, my schedule was so off that by the twelfth of thirteen patients that morning my sugar was low, my mood was cranky, and my thought processes had slowed to a crawl. Frustratingly, somewhere in the brain fog I recognized those last two patients did not get my best care. Did they recognize my distress or just think that Dr. Nieder didn't care about their needs? Statistically patients have a problem speaking up for themselves in a doctor's office[1,2] and in my own uncomfortable state of mind it is unlikely I would have picked up on their discomfort!

Someday, hopefully soon, the office will find the right balance in scheduling for our new system. For now, I'm taking a lot of deep breaths and hoping that patients know I still respect their time and am struggling to give them good care under difficult circumstances. 

1. http://healthecommunications.wordpress.com/2010/09/01/five-reasons-why-people-do-not-ask-their-doctor-questions/

2.http://newsroom.pamf.org/2012/05/patients-fear-being-labeled-difficult/

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?

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

An EHR Obsession

My Saturday morning walking partner asked me yesterday, "So when do you get to quit being an IT professional and go back to being a doctor?" Wow, good question.

In the not quite three weeks of this new form of documentation I have been consumed with trying to understand and make the EHR work for me. No longer do I have to consult a "superuser" every ten minutes with questions but every day I'm trying to figure out the most efficient way to care for people using this frustrating new tool. The "muscle memory" is beginning to kick in thank goodness, so time per patient is less. Now my frustrations are more with what seems to be a very inefficient system. I struggle to determine whether I am the problem or the EHR is. Most likely it's a little of both. The term Mission Hostile User Experience coined by Scot Silverstein comes to mind. What is scary here is the potential for patient harm - between my distractibility due to the steep learning curve of the Allscripts system, the fact that no one has told us how to clean these "Toughbook" fomites that we carry from one patient exam room to the next, and the patient care error potential inherent in the software itself, these are the ever present worries that keeps me up at night.

On Thursday of this week, the EHR Steering Committee for my organization will meet and I will have the opportunity to present the go-live experience and make suggestions for improvement as other offices in the system go live. Throughout this process there has remained a sense of re-inventing the wheel, which seems odd considering that Allscripts EHR has been in existence for years, having gone public in 1999.

At any rate this blog is obsessed with EHR right now--but the essential question remains. When do I get to go back to taking care of patients?

Patient response to Electronic Records

Amazingly my patients have had a very patient response to the introduction of EHR (Electronic Health Records) to our office. They sit and watch me type and curse with an air of amusement and calm. More calm than I am feeling.

Yesterday began our third week of EHR. Muscle memory has kicked in and I saw 15 patients without running too far behind. Seeing 20ish patients daily again is starting to look feasible. Someone walking into my office no longer has to look over mounds of paperwork to see me. My only concern is whether my employers will cease to understand how much work I do if they can no longer see the physical evidence of it.

On an up note, there will soon be a couch in the area where the credenza is now. Since my colleagues warn me that it will continue to take longer to finish my charts it seems reasonable to have a comfortable place to do so. The main purpose of the credenza was to support the hundreds of charts I needed access to on a daily basis. The staff is very supportive of the change as well (wonder why...).

Many patients have followed me over the 25 years I've been in practice. While little has been different in the exam room until now, there have been lots of other changes--two previous locations, private practice to employed doctor, hospitalists, urgent care centers, and oppressive insurance controls to name a few. For the first time in two weeks, I was able to gauge patient reactions to this new-fangled way of documenting. Prior to yesterday I was too bogged down with clicking boxes, losing screens, figuring out where to put a new symptom the patient just threw at me, finding templates and vital signs and generally being absorbed by the Allscripts system to observe my patients (and please don't make me worry about what I may have missed in patient care over the last two weeks while I followed this steep learning curve).

Now I carry this new contraption in the room:

My younger patients hardly notice it. They would not have commented had I not explained its newness and why it was taking a little longer to enter information than usual. Older folks regarded it with expressions ranging from dismay to perplexity. Most of them commented before I did.

• "Do you like it?" 
• "Do you think it will ultimately speed you up or slow you down?" 
• "How hard is it?"
• "Did Baptist (my employer) force you to do that?"
• "What happens when the system goes down?" (I wonder about this one myself)

No one seemed particularly surprised or overly worried about my use of a computer to document their visit. They all seemed impressed when I stood up and said that their prescriptions were already at the pharmacy. 

At the end of the day what most impressed and humbled me was the sense that within their acceptance of this new device was a trust that regardless of the way I document their care, it would still be delivered in a way helpful to them.

At the end of the day, that's what it's all about, isn't it?

Finding a Better Way Down the Electronic Pathway

Clicking on a link from Twitter this morning, I read an article about how distracting email is in the workplace. That got me to thinking so I googled "digital distractions" and found this amusing infographic by David McCandless: 

http://www.informationisbeautiful.net/visualizations/the-hierarchy-of-digital-distractions/

It's hard to see on my blog but my favorite part of the visualization are the words "partner shuts the lid of laptop on your fingers" encircling the star at the top. Sometimes I want to do the same to myself. One of the more physically painful manifestations of "too much computer" happened last week when my eyes began to sting, burn and water after going live with electronic medical records. Adding six more hours a day looking at the screen was some sort of ocular last straw.

In the risk vs. benefit analysis of computer use, where is the balance? Wednesday night I participated in an #mHealth twitter chat on the topic of "access to medical literature". This was primarily about researching tools and how to find articles but because of the chat, it occurred to me just how often I utilize Twitter to access current medical information. Most of my contacts on Twitter are involved in mobile health or patient care so lots of very relevant information is tweeted and I click on the links. From genomes to medical policy to the latest treatments for atrial fibrillation, it all comes across the feed and when I have a moment I click, read or save and go on with life.

It's still unclear to me how to balance my time, choose wisely with my clicks and still fill my life with all the other important moments. If someone else has found a better way down the electronic pathway, please let me know.