With an internal medicine practice as large and as busy as ours, it’s always felt like we’ve had tremendous advantages from the economies of scale. But can that be right?
We are an incredibly busy primary care combined faculty and resident practice in New York City, with more than 50,000 patient visits a year, which keeps us really, really busy. Walking through our practice the other day, I was struck, maybe more than usual, by the chaos we’ve created.
With over 300 patients scheduled to see us that Tuesday, from adolescents to our oldest patient of the day at 104 years of age, by mid-morning the place was already packed, with the line to check in out the door and stretching back to the elevators, and standing-room-only capacity in each area’s waiting room. An incredible array of medical issues lay ahead of us as providers, ranging from the benign and mundane to the incredibly acute and scary.
Patients were there to see us for so many of their healthcare needs — management of their diabetes, hypertension, asthma, heart failure. A bevy of upper respiratory tract infections, the flu, urinary tract infections, cellulitis. Low back pain, headaches, depression, anxiety, migraines. And of course a couple of patients each day are sick enough to need to be sent over to the hospital for a higher level of acute care, and just recently we had a patient in a somewhat stable ventricular arrhythmia who needed electricity really badly.
A Question of Size
Our schedules were full, the electronic medical record was humming away, patients were getting vitals checked, being seen in examination rooms, getting EKGs, getting nebulizer treatments, getting their vaccines, having their forms filled out, and refilling their prescriptions. The staff was handling hundreds of phone calls, sending and receiving faxes, getting prior authorizations, processing referrals, and scheduling appointments. A pile of papers teetered at each reception desk, over a foot high, waiting to be scanned into the electronic medical record (EMR). We even did a few video visits as part of our telemedicine pilot.
Have we gotten too big?
Our practice has two smaller satellite locations, where a small number of attendings and a cadre of residents practice in an environment that almost always gets higher marks in terms of provider satisfaction, and even on some measures of patient satisfaction and quality outcomes.
Meanwhile, our main location here right by the hospital has over 20 full-time faculty members, with nearly 100 internal medicine residents rotating through. On site here, we have 10 nurse practitioners, about a dozen nurses, about the same number of medical technicians, and a support staff that, while large, could always be bigger.
Looking across the schedules of everyone seeing patients, despite the fact that everyone has an assigned primary care physician (PCP), we often have an incredibly high rate of discontinuity, where someone is seeing a patient who isn’t theirs, who they’ve never seen before, and the only thing they know about them is what they’ve read in the chart. But in our smaller sites, the continuity indexes — the proportion of patients that are seen by their own PCP and the proportion of patients a provider sees for whom they are the PCP — are always higher. Every day down here, it always feels like we’re full to busting, whereas at the smaller sites, the demand is definitely lower, the pace is slower, and things in general seem less chaotic.
The Red, the Blue, and the Green
Our large practice site here is divided up into the Red, Green, and Blue practices, which represent the three geographical sections of the floor our practice occupies, and the attendings and residents that practice in each of these areas get those color appellations (I’m a Green Attending; she’s a Blue Resident). In addition, a Green patient is one who is seen by a doctor who works in the Green area, and we’ve even gone so far as to label them by color banners Red, Green, and Blue right in the EMR.
But we’ve noticed that when a patient calls to be seen, there’s often a scramble to find them a place — any place — to be seen. “I know your doctor’s not here today; they’re not here for another 2 weeks.” “But I want to be seen today; who’s available?” “I know you’re a Green patient, but there’s an opening in Red; do you want it?” However, when doctors are seeing patients they don’t know, they’re more likely to order more tests, to over-prescribe medications, to take a more aggressive approach.
I have several older friends who described to me their solo practices when medicine used to be a calmer, gentler, and quieter vocation. The internist or pediatrician or gynecologist would come into work with a group of patients scheduled to see them, all of whom they knew. What’s more, the front desk staff knew the patients, their nurse knew them, and their medical assistant knew them.
There was no pressure to pack patients on the schedule, to bill at a higher level of complexity, to crunch out those RVUs, or to click the boxes in the EMR to make sure we satisfied the gods of compliance and regulation. The doctor got to do the doctoring, the nurse got to do the nursing, and everyone did what they needed to do to take care of the patients. These doctors described to me seeing the patient in the exam room, and after that, the nurse would come in and draw the patient’s blood, and give them their flu shot, and do the EKG, and then the patient would pay their bill and go home.
A Possible Solution
We’ve created a system so chaotic and complex that it all feels like we’re treading water and trying to keep our heads afloat — all of us, the patients and providers. I know we, here at a large tertiary care academic medical center, will likely never be able to re-create the small town primary care country doctor vibe, but perhaps by creating a smaller, more closed off unit, we can get to some of that stuff we all wish we knew.
As much as siloing is seen as a bad thing in healthcare, we are going to try closing off the walls of each of our small practices — Red, Green, and Blue — to try and separate things and build a smaller team that really gets to know each other. The same attendings, the same residents, the same nurses, the same nurse practitioners, the same medical technicians, all taking care of a smaller group of people, in the hopes that we can forge a bond of community and collaboration that leads to more successful healthcare.
I’m sure it won’t be the small town country doctor’s office, that small room at the back of the doc’s house with a white picket fence and a garden out back, but if we can create a sense that everyone feels responsible and is able to get the work they want to do done, without all the rest of the noise going on around us, perhaps we can get to that kinder, gentler way to take care of our patients we desperately deserve, and which we know our patients want and deserve.
I’ll let you know how it goes.
Last Updated February 14, 2020
Source: MedicalNewsToday.com
