Shortcuts

"I work long hours, half of which are essentially unreimbursed."

So writes a passionate advocate of the patient-centered medical home in a newsletter dedicated to promoting the concept. By testimony of others, he is an excellent family physician.

My goal is to work short hours, and be reimbursed for all of them. This blog is dedicated to shortcuts – the kind that save time, without sacrificing quality.

The first shortcut that I specifically remember came from a staff neurologist at Womack Army Hospital, where I did my training. In a noon lecture he advised that when you get a woman who complains of a bitemporal headache that progresses to a hatband distribution and goes down the neck, you can stop listening. 

He's the same guy who advised that when a staff physician writes "WNL" in a note, it stands for "We Never Looked." He was kidding. He always looked, and we knew it.

Remember the "medical school physical"? The eight-page form with printed body parts that taught us the skills of physical diagnosis? The hour and a half that it took to perform? And the waste of time it would represent at our present level of experience? The key to a happy and productive practice is learning the corners we can safely cut.

Would anyone argue, with a straight face, that civilization has progressed by figuring out ways to do the same job, only slower? Of course not. But where is the research on productivity, or efficiency, in family practice? 

Many family physicians are demoralized because they feel like they're on a "hamster wheel."  When TransforMed tries to turn them into a patient-centered medical home, it seems to get worse. 

I don't feel that way. But I can't get a handle on why I'm such a distinct minority. Surely this is a more gripping problem for FP research than yet another survey tool designed to detect closet alcoholics. Lacking a research base, all I can do is make educated guesses about what makes me un-stressfully productive.

Could it be that from my first year of practice, I decided that I was going to work no more than 220 days? There are 262 Monday through Friday workdays in a year, so that's like 8+ weeks of vacation. Research: How is vacation time related to job satisfaction and productivity?

Could it be that I hire only experienced RNs, and pay them well? That way my turnover is extraordinarily low, I virtually never talk on the phone, and my histories are thoroughly documented when I walk on stage. Research: How is staff continuity and education level related to job satisfaction and productivity?

Could it be that I refused to dictate notes in the beginning, and refuse to adopt an electronic medical record now? That way I never had to read transcriptions after office hours, and I never look at a keyboard while giving patients my full attention. I use a check-box system (manual macros) and my notes are very cryptic – just enough so everybody knows what's going on. (For a really clever essay on this subject, see "Charting Then and Now" by Mitchell Cohen, MD.)  Research: How is time spent looking at or creating a medical record related to job satisfaction and productivity?

Could it be that I chose independent rather than salaried practice, so my take-home pay is influenced by every patient I see and every item I charge? That seems to help my attitude when I'm tired, and concentrates my mind on coding and business decisions. Research: Controlled for group size, how is salary structure related to job satisfaction and productivity?

Could it be that my determination to be physically fit contributes to the speed of my decision-making, and my stamina when examining the 26th patient of the day? Research: How is physical conditioning, measured by peak METs on graded exercise testing or the timed one-mile walk related to job satisfaction and productivity?

I have more questions, but that's a good start. And it makes me wonder: After four decades of academic family medicine, why don't we have more answers? If family practice goes down the tubes for economic reasons, the dearth of productivity research will be a root cause.

In the meantime – I'm not holding my breath – some of you might report on your anecdotal experience with my hypotheses (or your own). And you rookies might try testing them for yourselves.

Posted at 03:54PM Apr 27, 2009 by Doug Iliff  |  Comments[4]