Tuesday Night Wine-Buzz because fuck it; I saw twenty-four goddamned patients today...

[Aristus]

I've got three more days to get through this week. I'm having a couple of drinks...

[Sanity Claws]

1. Tough schedule

But I am concerned about your drinking. You are in medicine so I know you are aware of alcohol's deleterious effects.

[Aristus]

2. I know, and thank you.

I'm currently treating a patient for advanced cirrhosis. He's up for a liver transplant. His life is not good right now.

I'm not to that point. I'm done for the night...

Thank you...

[HipChick]

3. I thought Wine was good for you.

[Aristus]

4. My patient drank the hard stuff. A lot.

And too much wine is like too much everything else. I'm trying not to go too far...

[HipChick]

5. I guess I'm fucked then...

I always have a glass of wine before turning in for the night..

[Aristus]

6. No. A glass of wine a night is just fine.

I drank 3 or so tonight. That's less fine...

[Skittles]

7. you really like to talk about your job

[Aristus]

8. I love practicing clinical medicine.

But for some reason, for the last few weeks, they've kicked up the scheduling to insane levels. I saw 24 patients today, and have 24 more on for tomorrow. One of my colleagues, an MD who works upstairs from me, got tagged with 30 patients in one day last week. That's insane...

[Skittles]

9. maybe it's what seems to be happening everywhere

more and more, they want workers to keep give more while doing with less - and the people at the top keep taking more and more

it would be very bad in your profession, because you could end up seeing the results of burned out and fed up people

[Aristus]

10. Every time I look in the mirror...

[3catwoman3]

17. I don't know about your clinical setting, but in the peds...

...office where I work, the electronic record keeping seems to take soooooooooooo much longer to complete. We each schedule 3 patients an hour, and I am seldom able to close a chart at the end of a visit. I routinely take home 2 hours of charting every day.

I HATE ELECTRONIC MEDICAL RECORDS!!!!!!!!!!!!!!!!!

[Aristus]

18. I actually love our EHR system.

It's one of the reasons I don't want to quit working where I am. I'm worried that another system won't be as user friendly,

Nearly the entire thing is just point-and-click. And it has an auto-text feature in which you can add huge amounts of pre-loaded free-text with just a few designated keystrokes. I can chart very fast. I almost always close out a chart right after the visit and before moving on to the next patient. If I wait too long afterward, I forget the specifics of a visit.

At the end of the work-week, I rarely have more than two or three charts open. I have colleagues who have as many as sixty to eighty charts open at a time. I don't know how I'd be able to chart all of that after the fact...

[3catwoman3]

20. We use a system called EPIC...

...which I am told is one of the better ones. It's the only one I have had to use, so I have no standards of comparison. I have been a nurse practitioner for 40 years, and I will freely admit that the transition from paper to computer was excruciatingly difficult. We all had auto-tutorials to do beforehand, which were absolutely worthless. My "practice" electronic patient was a 57 yr old man on Lipitor - something I would never deal with in pediatrics, of course. I thought the least that could have been done was to give me a 5 yr old with an earache. It was bad enough trying to master all the new technology. A familiar clinical situation would have been comforting.

Each section of an encounter has to be accessed separately - the CC, the HPI, the ROS, the PE. Then there is a separate section for assessment and plan, and that itself has at least 5 subsections - level of service, diagnosis, meds and orders, follow up, and charge capture. Many of the point and click choices for the PE are very stilted and pro-forma sounding, so I have created many of my own templates that read like they would when I was handwriting charts. I want my work to sound like something I have done, not a repetitive rubber-stamp style with no individuality.

Insurance cannot bill under my name, so, in addition to everything else, I have to go in to the level of service and the charge capture to take out my name, and put in the name of which ever pediatrician I am working with on a given day. That little requirement itself is a 14 step procedure, which is entirely secretarial and not in the least clinical.

In pediatrics, there is a lot of parental education needed. It typically takes every moment of a 20 minutes visit just to get the face-to-face interaction done. On a good day, it takes about 10 minutes of computer time to close a chart on a straight forward case. If I see 15 patients a day, that is 150 minutes of documentation time.

Well, rant over. I am lucky enough to only work 2 days a week, and to now be 65, so retirement is only 2-3 years away.

[Aristus]

21. Ours is AllScripts

I've used Epic before. One of the local hospitals uses it, and I did a few rotations there. It's not as fast or user friendly as AllScripts.

[3catwoman3]

22. It would be interesting to compare.

This one was apparently chosen for use because of our affiliation with Chicago Children's Hospital, because it is what they use, so we are stuck with it. I feel as if it takes me 3 times as long to document by computer than it did by hand. Plus, I can't type and listen at the same time. Especially if I have a weeping mom in front of me (not uncommon in pediatrics, even if there is nothing serious wrong) - she needs and deserves my full, direct eye contact and attention.

I would rather take care of patients, not computers.

[Aristus]

23. I hear you.

I've become very good at memorizing lots of information.

When I have a new patient and need to take a complete medical history, I put my laptop on the counter, face my patient, and do everything face-to-face.

I don't enter anything on the computer until I get back to my office. My patients always say things like "You really listen!"

I'm sure they've had providers in the past who keep their heads buried in their software the whole time, not looking at the patient, and just saying things like "Uh-huh. Uh-huh. Yeah, uh-huh."

Now I'm pretty sure those providers actually are listening and absorbing the information, but that's not the impression the patient gets.

[pinboy3niner]

46. My last PA at the VA was great

He did the face-to-face while doing his computer history entries at the same time so they would be fresh and accurate. He also spent a lot of time with me on every visit, more than I expected, and liberally ordered tests for anything of concern.

He is an immigrant from India so there was a window of a month each year when he had no appointments so he could make a visit to family in India. Fine with me, I was happy he had a chance to do that and that I had such a dedicated and conscientious PA for my primary.

I hope your schedule settles down. It must ber a real struggle for you to feel like you're doing justice to your patients at that pace, not to mention the strain on you.

[AgadorSparticus]

47. I do locums in different settings and have worked with various EMR's

And Allscripts is hands down my favorite. It is fast, easy, user friendly, and has a good mix of intuitive text and tree text. I also like the T system. The worst for me was actually epic. But I think that not all epic is created equal. It depends on where you work and how they developed it.

[clarice]

30. A sad state of affairs in the medical field nowadays. nt

[Skittles]

32. it's not just the medical field

I have worked 18 nights straight, and that is 12 hour night shifts

[clarice]

33. wow...if I may be so bold... are you paid overtime? nt

[malthaussen]

48. The test-to-destruction is almost complete, IMO.

I grit my teeth whenever a pol talks about the need to increase productivity. Even Dems recite that shibboleth. The only thing increasing productivity has done is make the rich even more obscenely rich.

-- Mal

[hunter]

11. Assembly line medicine isn't good for anyone...

...except the big money players of U.S. medicine.

The practitioners on the front lines are not the big money players.

Many of the big money players don't know shit about medicine. All they see is the $$$. If their revenue streams are increasing they don't care if they are harming patients and their front line medical care providers.

[Aristus]

12. The trolls who hide under the General Discussion bridge think I'm one of the big money players.

Whenever I post about wanting my patients to quit smoking, or denying opioid meds to obvious drug-seekers, they go berserk, calling me a quack who just wants to make Mercedes or yacht payments.

Yeah, I wish...

I haven't had more than a week off in a row in over three years. And when I get a week off (like next week, thank God) it's usually a staycation...

[Sanity Claws]

14. Now that you have so much experience behind you

is there a job you could take that would be less demanding? Or is your office typical of all medical clinics?

[malthaussen]

49. One DO of my acquaintance...

... takes a "vacation" every year -- to a professional conference to enhance his understanding of medicine. I don't believe the chap has any time for leisure at all, although he does watch the occasional movie on Netflix.

-- Mal

[Aristus]

51. Yeah, I go to those twice a year.

It's the best way to get 50 hours of yearly continuing education in order to maintain my license.

[Kaleva]

13. Trump saw twice as many.

[Aristus]

16. "And they were the best, all right? Just the best patients ever. And I saw 'em. Saw 'em all!"

My practice of clinical medicine is yuge! Yuuuuuge!"

[NNadir]

42. Their recoveries were fabulous! Fabulous! Obama made them sick...

...and I'll tell you what, when I'm your physician, all of the diseases Obama brought from Kenya will be cured and we'll have the best cures ever! It's gonna be a YUUUUUUUGE medical recovery!

Except Muslim patients...

[lunatica]

15. I'll drink to that!

Cheers!

[Aristus]

19. And to you!...

[In_The_Wind]

24. It's time for a Brat and Apple Cider break. Replanting pond plants is thirsty work.

Oh, and my neighbor's cat loves hanging out in my yard.

[Aristus]

25. Make mine a hard cider, and you're on...

There are a number of distilleries here in Washington that produce sublime hard ciders...

[In_The_Wind]

26. Ugly Apples make better hard cider. Yes, I've got a small buzz going.

No spray organic apples may have an ugly appearance but are still sweet ...


https://www.washingtonpost.com/lifestyle/food/how-do-you-like-them-organic-apples/2012/10/01/15d3072a-0980-11e2-a10c-fa5a255a9258_story.html

[Aristus]

27. Enjoy!

[clarice]

34. Hey !!!! Me too !!!!! Makers Mark whiskey for the Lady please.nt

[Aristus]

39. For you...

[clarice]

43. Such a Gentleman....thank you Sir... I hope your intentions are honorable......

I would hate to think you a Cad.

[clarice]

31. Those are beautiful Koy.nt

[In_The_Wind]

41. Those aren't mine but they look and act the same.

My pond has lots of this going on.




Oh, and Queenie looks and acts just like this when she drinks out of the birdbath next to the pond.

[JustABozoOnThisBus]

28. Is this partly due to ACA?

Many more people got insurance.

I don't think a proportional number of MDs were cranked out.

?

If a couple of drinks are prescribed, who are you to argue?

[Aristus]

29. Is that an anti-ACA crack?

Because I support the ACA 100%. I will support a single-payer system 100%.

Other organizations have nurse triage at the front desk determining things like: "This needs to be evaluated and treated today. This can wait. This requires emergency treatment. Please go to the ED; I will call and let them know you are on your way."

We don't have that. All we have is a policy that says" If you show up, you will be seen." On the surface, it seems reasonable. In practice, it's insane. In between diagnosing, treating, and referring for specialty treatment patients with atrial fibrillation, chronic kidney disease and so on, we have to take time for patients who have "a thingy on my pinky. Had it for years. Hurt? No it doesn't hurt. I just want to know what it is" or a three pack a day smoker complaining about a cough he can't get rid of, but refuses to quit smoking.

[clarice]

35. Perhaps I have a bit of a buzz on as well....but..

the medical personnel that I talk to in Texas have had a very hard time with ACA policies.

[Aristus]

36. Well, I have a problem with the fact that it was a huge bone to the private insurance companies.

But it was better than the nothing the Republicans were offering. The Federal subsidy that accompanied the plans made health insurance available to nearly all of my homeless patients, back when I was working at the homeless clinic. If the equation ends with more patients having access to healthcare, rather than fewer, I'm cool with that.

[clarice]

38. I think that those I have talked to resent the ASTOUNDING amount of extra paperwork involved. nt

[Aristus]

40. I can appreciate that.

But if the end result is access to healthcare, I would postulate that it is worth it.

All day, every day, I have to do prior authorizations for medications that are optimal for a patient's treatment, but aren't on the insurance company's formulary. And although I hate the paperwork, if it gets my patients what they need, I'll do it.

[clarice]

44. Most commendable. nt

[JustABozoOnThisBus]

37. No, I'm pro-ACA (as a step toward single-payer)

But, it seems to be a "supply/demand" consequence. More people can now see Primary Care Physicians for routine medical maintenance (a very good thing), but the supply of MDs is not increased at the same rate.

Hopefully, we will expand medical schools to meet the demand. Hopefully, we can figure out a way to make the education affordable.

It wasn't intended as a crack.

Regards.

[malthaussen]

50. Might not have been a crack against ACA...

... but it does raise a question that has long interested me: is there enough health care to go around? I really don't know the answer to that. In classical economics, any commodity is subject to the laws of supply and demand. If there is not enough health care to go around, then it's necessary to either: increase productivity (which is subject to the rule of diminishing returns), increase the number of providers, or let some people fall through the cracks. If there is a fourth way to address the shortfall, I can't work it out. Insurance companies then become pimps to provide health care to those who can afford it.

If there is enough health care to go around, then the problem doesn't arise, but it would appear that something has to be done to manage it better, since it is so irregularly provided.

-- Mal

[Texasgal]

45. Wow! That's alot!

We had 8 scheduled surgeries and 6 follow ups and I thought I was going to die!

Tomorrow is chart day so we can catch up!

Enjoy your well deserved cocktails!