A "leave of absence".....what I really mean by that is I have reduced the number of patients I see a week to about half what I used to see and am still working the same number of hours per week.
I've realized that physicians underestimate the toll that seeing our patients daily takes on us. I mean think about it - we listen to the complaints of sick people ALL. DAY. LONG. And, our job is not just to listen, it is to fix them. And, our job is not just to fix them, it is to fix them in less than 7-10 minutes on average. And, in addition to fixing them in less than 7 minutes on average, we are also responsible for:
1. Documenting a complete note about their visit that day meeting all requirements of the insurance company (After all, as the saying goes in protecting yourself from litigation "If it isn't documented, it didn't happen.")
2. Choosing the correct list of diagnostic codes out of a book containing 68,000 choices
3. Ordering the right tests so that we don't miss a medical diagnosis
4. Ordering enough tests to satisfy the patient about whatever they have been googling
5. Ordering only the tests that the insurance company will pay for
6. Refer to specialists as needed but only to whom their insurance company deems to be the "right" specialist
7. Prescribing the right medications for the patient but only the ones that their insurance company will pay for
8. Reviewing "Patient Health Snapshots" (as they are called by one insurance company).
This "Patient Health Snapshot" is a document that we obtain by logging in to the insurance company's website and looking up the individual patient. It tells us what the insurance company thinks the patient needs - such as being overdue for their colonoscopy or mammogram, or needing an eye exam, or receiving certain immunizations, or that the patient's blood pressure is too high, or that they are not getting their medications filled at the pharmacy frequently enough. And yes...this too we are also supposed to address with the patient...in those few minutes.
(Why in those few minutes? Because of the fee-for-service model of healthcare, those are the only few minutes that we are paid for. Work done to take care of patients when they are not in the office is not compensated for. And further, not adequately addressing these Patient Health Snapshots actually means we get paid less. So now, if we are seeing a patient for a rash and it happens that they are also not getting their cholesterol medication filled at the pharmacy because they have heard about statins on TV and refuse to take it, our payment continues to be affected unless we convince them to start taking it. Which all in all means we need to see more patients to meet equivalent reimbursement and now the 7 minutes we did have has decreased even more.)
Is it any wonder we're concerned about medical errors, high costs and poor outcomes in our healthcare system? Practicing medicine in America is insane. And as Albert Einstein said "Insanity is doing the same thing over and over again and expecting different results." So, I'm trying to embrace the upcoming changes in healthcare by prioritizing initiatives such as making our practice a Patient Centered Medical Home (PCMH) and preparing our current patient base for the upcoming MACRA shift. It's estimated these projects take 12 months. We need to do them in 6. 6 months of work that I won't get paid for... yet. Hopefully, it will pay off in the year 2019 when reimbursement for MACRA goes into effect. It's now been determined (source here) that on average 20 weeks out of the year are spent within a single physicians practice reporting quality measures...20 weeks is insane. That's not 20 weeks spent taking care of patients, that's half a year reporting to our insurance companies who then report that data to the government about our patients health. Thank goodness I have amazing CRNPs that are helping me with the actual day to day patient care. Without them, I'd be out of business right now. Due to MACRA beginning in 2019, it's estimated that 87% of solo practitioners will begin receiving reimbursement penalties, which will ultimately drive these practices out of business.
So while a lot of non-health care providers try to reform our healthcare system in ways that will probably only make it worse, I've got to take care of my patients, myself and my family. My "leave of absence" effectively means that I'm seeing half the number of patients I used to while working the same number of hours for less pay in order to add in administrative tasks like implementing PCMH and tools to better report quality measures. It's not really the leave of absence I would dream of:) But, it's better than continuing the sleep deprived, burned out, unhealthy state of being I was quickly making a habit of which was likely to just leave us among the 87% that were going to be headed out of business anyway.
In a physicians training, we're trained to put the patient first. Beyond that, we're trained to be heroes that can tackle any problem on our own perfectly. It's not exactly thought of as a positive trait in medical school to have a growth oriented mindset, make mistakes and learn to ask for help. We quickly learn that we have to set aside our emotions to witness horrendous suffering and try to be the one that can help. We realize that we have to sacrifice our own health sometimes to do this, our relationships suffer, our emotions have to be set aside. And when we take that hero/perfectionist component of our training and enter the healthcare system we are working in, it just doesn't work. It doesn't work because it's not possible. It's not possible to do everything that we are held responsible for (that is actually out of our control) in 7 minutes of time with the quality in which we want to do it. It leads to a lot of burned out physicians cynically practicing medicine. As much as I genuinely love my patients, I've realized that without boundaries, these two sweet souls pictured will suffer, not to mention myself and my dear supportive husband. And so, that is why, I am taking my "leave of absence."
A few weeks ago, I had a wake up call given to me by my youngest son, 2 years old. It was my off day. You would think I'd be more relaxed on these days spending a mommy-son day together. But, when you've been up late working the night before (and the night before and the night before and on and on) and you're still depressingly behind on everything needing to be done and are also intermittently answering calls/messages/texts/emails from office staff and patients AND trying to be present with your children, it's an extreme test of mindfulness. That afternoon it was time to go pick up my daughter from school and I'd been delaying my son's nap until we all got home so it wouldn't be interrupted by having to leave to go pick up his sister. So, of course, he's napless and tired and I'm in my usual state of exhaustion. I wanted him to use the bathroom before we left so he wouldn't have an accident in the time we'd be gone. After telling him it was potty time, I went to the bathroom to wait for him to follow me as he typically would do. This time, I waited and waited. It must have been oh maybe 15 seconds, it felt like 10 minutes. We're going to be late, I'm thinking. And for some reason, I just totally snapped. And you have to understand, I don't do that. I'm calm, cool and collected. I can count on one hand the number of times I remember yelling in my entire life. But this time, I yelled. I yelled at my son for taking 15 seconds too long to come to the bathroom. As soon as the words came out, I was already teary eyed. Then I looked up through my tears and saw my sweet son crawling into the bathroom. He looked up at me with a look of fear, confusion and such sadness and said "I was coming. I was crawling. I don't like it when you do that." He wasn't even disobeying, he really was coming, just not fast enough for me. He just was playing a game with his stuffed animals and was pretending to be a baby and crawl with them. And, I didn't have 15 seconds to wait.
I realized in that moment that my life was not working for me or my children. I mean sure there had been signs before but that was the moment looking at my son through my tears that I was convicted.
I've told my husband, who is thankfully also the Practice Administrator at our clinic, that this next few months is an experiment in figuring out if we can survive the next 20-30 years with a medical business under the ACA. Time will tell...
Brooke Uptagrafft, MD
Dr. Brooke is a family medicine doctor.