A Day In The Life:

Four days a week my days are basically the same: 

Alarm goes off at 6 am.  I go into autopilot.  Grope my way into the shower.  Wake up.  Cerebrum moves up to 80% functioning.  Pad quietly back into dark bedroom where my wife is sleeping and try to get dressed in the half-light (boy it is hard to tell black socks from dark brown socks from blue socks!).  Quietly head downstairs and put together breakfast.  Let the Corgi out, then in.  Get the newspaper.  Have a quiet breakfast while reading the news.  Hopefully cerebral function is close to 100%. 

Put together something for lunch.  Head back upstairs.  Put the Corgi in bed with my wife (the terrier is already in bed). Kiss my wife goodbye (she'll be getting up in an hour to go to work).  Drive to work (3 minutes, 2 miles).  Hopefully at my office desk by 7:00 am as the first patient is being roomed by my most excellent Medical Office Assistant (MOA). 

My patients are scheduled every 20 minutes, with 40 minutes set up for physicals, or new patients, or patients that I know are more complicated/need more time.  However, one of the biggest challenges I and my MOA face is making sure patients arrive on time. 

I am obsessive with running ON TIME.

My MOA has a huge list of things she needs to enter into the electronic (computerized) medical record.  She has to get the patient's vitals (blood pressure, pulse, temperature, weight, sometimes height).  Then she has to go over the current issue we are dealing with that day ("chief complaint"), and then go over the patient's current medications, making sure our records accurately reflect what they are actually taking (obviously an issue of HUGE risk if wrong).   She has a whole long list of other questions, most of them in an effort to update the medical record so that everything is accurate when I walk in the door. 


The MOA's data-gathering can easily take 10 minutes.  So if my patient is told their appointment with me is at 10:00 a.m., and arrives at the front desk at 10:00 a.m., by the time my MOA is finished with her data-gathering, it is then 10:10 a.m, and I have only 10 minutes to spend with the patient before I am scheduled to be in the next room with my next patient.  I do not feel I can adequately LISTEN to the patient's issues, do an appropriate exam and then make recommendations in 10 minutes.  We have brainstormed all kinds of ways to address this issue. 

My MOA will call my patients a few days before their appointment and ask them to be there 10-15 minutes prior to their appointment time with me, just for this purpose.  However, MY proposal to our office system is to use the TEAM appointment philosophy.  I believe we should tell our patients that they have an appointment with their medical TEAM:  MOA, physician, and RN (at the end of the visit).  Patients should be given an appointment time to arrive at the clinic that REALISTICALLY reflects the time the MOA can begin her data-gathering, then my 20 minutes, then possibly another 5-20 minutes with the RN or in the lab or whatever else might be needed before the patient leaves the building.

So, back to the daily schedule:  I walk in the exam room with my first patient of the day, anticipating a 20 minute visit.  Generally on average this is no problem.  A significant percentage of my daily office visits are "re-checks" of stable, long-term medical problems such as hypertension, diabetes, depression, headaches, asthma or other problems that are under control and just need periodic office visits to update the status and make sure the medications are working, and that things remain under good control. 

If a patient's long-term chronic problem is not under good control, then we need to spend a little more time brainstorming what we (both the patient and I) can do to try to get things again under control.  If the patient has multiple problems (diabetes AND hypertension AND high cholesterol AND arthritis) and ALL of them are out of control, that can quickly move a 20 minute visit into a 30 minute visit as we attempt to address all the issues.  This is okay with me; it is more important to me that we get the patient's problems resolved.   Chances are good that the schedule will "average out" ok over the next hour or so anyway--often the next patient will only need 15 minutes and I can start to catch up. 

If it is clear that the patient is presenting with a long list of problems, or has several difficult problems that need a lot of attention and I am limited to a 20 minute visit, I will have to "divide and conquer."  That is, I will have to work with the patient to determine the highest-priority issues to address in our somewhat limited time.  We then set up a follow-up appointment in the near future to continue to work on the list. 

So my schedule moves through the morning like this.  I may have perhaps one "no-show," meaning a patient simply doesn't show up for their appointment.  This is very frustrating for me, but it has positives also.  The negatives:  I cannot update the missing patient's medical status, I cannot provide appropriate care for the missing patient, AND some other patient who has been waiting for an appointment now cannot be seen in that time slot because the missing patient did not cancel their appointment when they knew they wouldn't make it.  The small positive is that I get a chance to catch up with phone calls and messages from my nurses. 

In between patients throughout the day, I stop at my main desk computer and check for phone messages from patients sent to me by my nurses, prescription refill requests from the nurses, patient lab and x-ray results, and e-mail requests from patients.   I also sift through the mountain of faxes regarding my patients from the 2 local hospitals and other specialist physicians who have seen my patients.  I also have to fill out forms or sign nursing home orders.  If I am on call that day, I have to do many of these same things for not only my own patients but for the patients of any of my partners who might be out of the office that day. 

Generally I finish the morning pretty close to noon.  My noontime routine:  Call my wife and check on how things are going with her--new developments in her life/work, things going on at home, who is doing what that evening.   Then I grab whatever lunch I threw together, and get on my computer to work on more phone messages or prescriptions refills:  things I can do while eating lunch. 

Occasionally there is a lunch-time meeting, during which I eat lunch at a meeting table discussing something of administrative importance.  But in doing so, I am getting behind on the constantly-piling up phone call messages from patients routed through my nurses. 

Once I finish actually eating lunch, generally I have about 40 minutes or so to catch up on my charting of my interactions with patients of the morning.  Try as I might, I generally do NOT finish all my charting on a patient during my 20 minutes of assigned time for that visit.  So then I go back through my schedule of the morning, identifying visits that are not "closed;" that is, still have to be finished with regard to documenting their problems, exam findings, and my "assessment and plan," which outlines what I think is going on and what we are going to do about it.  I then type in my notes and findings and plans, or else (if more complicated), dictate my notes through the computer.  With any luck, I'll have finished (closed) all the morning's office visits by the end of my "lunch hour." 

NOTES ABOUT THE ELECTRONIC RECORD OF AN OFFICE VISIT:

In the computerized medical record, when a patient comes in for a visit (termed an "encounter") a complete documentation of that episode is required.  Basically, this is what is involved:

Demographic information:  the front office staff enters the patient's insurance information, updated address, etc.

MOA's information:  as described above:  vital signs, medications, updated medical history.

MD's information:  This takes on a time-honored format called a "SOAP note:"  S:  subjective information--information coming from the patient regarding their problems, complaints, symptoms, and anything they want us to know.  O:  objective information--information coming from direct observation, such as lab work, imaging/radiology, physical examination findings, vital signs, measurements. (Terming this data as "objective" is of course something of a misnomer--physical examination findings and imaging results are often very subjective.)  A:  Assessment--what I  as the physician (with the input of the patient) think is going on.  Diagnosis, hypotheses, ideas.  This is, in my mind, the most important section of the entire record.  P:  Plan--what I and the patient have determined is the most appropriate course of action based on our assessment.  For example, changes in lifestyle, changes in medication, further diagnostic options (lab work, testing, imaging), and how we are going to follow up on these changes.

The end of the "encounter" document will include medications ordered, immunizations given, referral orders if the patient is being sent to a specialist for consultation, and any printed instructions for the patient to follow. 

The last thing I do prior to "closing" a patient visit entry in the electronic medical record is determine the billing "code" for the office visit.  The details and idiosyncrasies of billing is the subject of another entry on this blog.  Basically, I have to determine--based on the time, effort, difficulty, complexity, or urgency of the issues addressed--how much should I charge for the visit.  This is arguably one of the most difficult parts of the job.

Back to the day-in-the-office: 

I start my afternoon schedule at 1:00 p.m.  It is exactly like the morning.  Running from 1:00 to 6:00 p.m. with patients every 20-40 minutes, trying to stay caught up with the phone calls, paperwork, prescription refill requests, and charting on patient encounters.  I generally finish up seeing patients around 5:30 or 6:00, and then spend another 30-60 minutes "cleaning up."  That is, finishing my visit notes, "closing encounters," finishing up phone call questions and prescription refill requests, and making sure the nurses are all set to go. 

If I am on call, then I might get a couple of phone calls in the evening from the nurses that staff the after-hours phone center.  I have to say, that the evolution of after-hours call has improved dramatically over the past 20 years.  Many years ago, if I was on call, I could expect 10-20 calls a night directly from patients, mostly very minor questions of typically a triage nature--should the patient go to the ER, PromptCare, or is it something that can wait at home and be seen in the office in a few days--that sort of thing.  Since plugging the after-hours phone calls through a Nurse Call system employing skilled and experienced RNs who can make these decisions, the number of calls that get filtered out and never reach me is huge. 

Hospital Coverage: 

When I started out in practice in McFarland, Wisconsin, I had a hospital-based practice also.  That is, I would care for my patients if they landed in the hospital.  That of course meant that every morning, I'd  stop at the hospital(s) and see the few patients I might have there, go over their progress, write orders on them, and make sure things were progressing.  I'd then get to my office around 9:00 a.m., and start my clinic practice for the day.  If I needed to, I'd stop at the hospital on my way home and check again on the inpatients under my care. 

As I got busier, my call partners (who worked at a different clinic) and I rotated hospital responsibilities.  That is, on our "call day" we would make hospital rounds on all of our group patients.  So one in four days a week, I'd see my other three partners' patients in the hospital, and I could start in my office a little earlier on the days my partners made rounds on our patients. 

I went through various permutations of call groups and call schedules over the first 15 years of my practice in Wisconsin.  The perpetual problem:  do we maintain a large call group of many physicians so that we can be "off-call" for long periods and just accept that we'll be ridiculously busy on the few nights a month we are on call, since we'll be covering for many doctors?  Or do we just stay with a small call group of 3-4 docs so that we are on call much more frequently, but hopefully much less busy when we are on call.  Some of my partners, when I was a member of a large call group, would have anxiety attacks on their days on call anticipating getting deluged with calls and 5-6 hospital admissions.

Call responsibilities also meant that if one of the patients I was responsible for came in to the hospital ER and needed to be admitted, I would be called in to do the admission processing and get the patient situated into the hospital.  An average night time hospital admission from the ER would take approximately 2 hours, not counting commute time.  For the majority of my practice years in Wisconsin I lived about 30 minutes from the hospital (I know, I know, my own choice!--but isn't it odd how in many cities the hospitals are located in the seediest areas of town), so that getting called to a middle-of-the-night hospital ER admission would take 3 hours from getting out of bed to getting back in bed (if I was lucky enough to get back in bed). 

On my arrival in Bloomington in 2005, all that changed.  The hospitals in Bloomington were going through a major change that almost all hospitals around the country have made:  they were employing "hospitalists" to manage the inpatients.   Studies were showing that physicians who were basically dedicated to managing the in-house hospital patients and were available 24 hours a day, 7 days a week dramatically improved efficiency, care, and safety of the hospitalized patients.  The system also seemed to significantly shorten hospital stays.  So it was seen as a major improvement for the good of the patient and the hospital.  Of course, it was a major boon to the lifestyle of primary care doctors, who no longer needed to divide their time and attention between the clinc and the hospital. 

I can clearly attest to the frustration of working in a busy outpatient clinic with patients waiting in the waiting room, then being called to go to the hospital because of an emergency with one of my hospitalized patients.  So I'd have to cancel a couple of hours of patients' visits right then and there, making apologies as I was flying out the door to race to the hospital. 

The advent of hospitalists has proved a positive impact on almost every aspect of care, except I think patients, as a general rule, don't like it.  They don't know these hospital physicians, and of course would rather be dealing with their primary care physician during their most needful time. Unfortunately, I don't have an answer to this.  It is how things are now.  I don't have enough time in my work day to make rounds in the hospital and maintain my current clinic hours and maintain any semblance of sanity. 

So I pack up things around 6:30 or 7:00 p.m. each evening, and make my way home.  On reflecting how the day went, I realize that when I am in the room with the patient, isolated from the hubbub of the clinic, just fixated on the issues at hand and how the patient's problems are affecting him/her, I am completely at home and content.  Admittedly, some problems are very thorny and difficult, but still, while it is just me and the patient problem-solving, I feel like I am in my element.  I enjoy that facet of medicine immensely.  Trying to solve a challenging issue.  Using my 26 years of experience to draw upon to figure out how I and the patient, together, can work toward a solution. 

If the day has been heavily loaded with very complex problems with very few workable solutions, then I can feel that stress by the end of the day.  Usually, however, things even out pretty well.  Some days, it feels like everyone is doing great, and there have been relatively few major challenges, and those days really keep me going.  Probably the factor that makes me feel the most tired by the end of the day is NOT the problems the patients and I have been working on, but the amount of extra work--the phone calls, the forms needing filled out, the lab results that need addressing--those "extra" issues (which of course are a normal part of any practice) really just can sap my time and energy.  But thinking about "shooting the breeze" with some of my well-established patients or families, I feel like I really am making a difference in their lives, and that gets me going for the next day.