Monday, June 2, 2008

physician demoralization - Walking in Doctors' Mocassins

Until you walk a mile in another man’s moccasins you can’t imagine the smell.

Robert Byrne, 1911 Best Things Ever Said, Robert. 1988

My name is Chief Moving Forward. I have gathered together you promulgators of federal rules and regulation; you promoters of guidelines, protocol, and science-based evidence; you proponents of pay-for-performance and outcomes measurement.

I invite you to spend one year walking in the moccasins of practicing physicians.

The Split

I have split you into two sections – those who will walk in the moccasins of specialists, and those who will spend your year in the offices of primary care physicians. For those among you who regard “walking in another’s man’s moccasins,” as too colloquial, think of what you’re about to do as “management while walking around.”

First, Specialists

Let’s begin with the specialists, and let’s start with a specialist who I interviewed last week. Dr. Melvin Seek is a 53 year old nephrologist who heads up an eight man kidney group in Ocala, Florida. Doctor Seek works 80 hour weeks, seeing patients, overseeing five dialysis units, covering 3 hospitals in Marion Country, which is about the size of Rhode Island, and serving as president of Healthy Ocala, a ten year old RHIO (Regional Health Information Organization) that sells personal health records to businesses.

Dr. Seek’s group has had an EMR for 8 years and finds it useful. He says, however, for most physicians, EMRs have been counterproductive – too expensive, too little ROI, too time-consuming, and of little value as a communication document between doctors and between doctors and patients. Instead EMRs have been a legal, documentation, and compliance document – a sort of giant invoice.

One of you please walk in Dr. Seek's moccasins for a week, and then advise how your various approaches can shorten his week, improve the quality of care, improve outcomes, and maybe even enhance his efficiency. I am sure he and other specialists would like to hear what you have to say and share your wisdom, after you’re spent time in their shoes.

Next, Primary Care

According to Frederick Bloom, Jr. MD, director of quality and performance improvement for the Geisinger Health System, “Studies have estimated that a typical primary care physicians would require about 10 hours per day to address all the chronic care needs, another 7 hours to address preventive care needs, and an additional 5 hours per day to meet the acute care needs of his or her patients.”

That totals 22 hours. Given this time-consuming reality, if a primary care doctor is to function optimally, he or she would need a team to whom to delegate. The trouble is, of course, 80% of primary care doctors practice in groups of 4 or less, run overheads of 50% to 70%, and already work 25-patient, 50-phone call days. This leaves scant time to meet or consider all requirements of protocols and guidelines.

While you’re in the doctors’ moccasins, I ask you to keep a notebook indicating in what percent of patients the diagnosis or treatment is “science-based,” or simply commonsensical and individualistic, based on the needs of the moment at the point of care.

Also I’m sure practitioners would like to know how your various approaches and measurements can be implemented in the time available, how they would cut overhead, achieve efficiencies , and improve outcomes.

Reporting Back

Once you’ve walked in the moccasins of specialists and generalists, I would like for you to consider revisiting and possibly revising how to make your approaches less time consuming, more streamlined, relevant, and user-friendly. You might also estimate doctor’s dollars per hour income, and compare it to your own once you’re put back on your own moccasins. This would help put matters in perspective and give you a sense of smell of what doctors go through.


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