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I realize that my blog has been littered with depressing musings on healthcare lately, and so I thought I’d offer up one very positive and “actionable” suggestion for all you patients out there. In the midst of a broken system where your doctor is being pressured to spend more time with a computer than listening and examining you, where health insurance rates and co-pays are sky-rocketing, and where 1 in 5 patients have the wrong diagnosis… There is one “magic” question that you should be asking your physician(s):
“What else could this be?”
This very simple question about your condition/complaint can be extremely enlightening. Physicians are trained to develop extensive “differential diagnoses” (a list of all possible explanations for a set of signs and symptoms) but rarely have time to think past possibilities 1 through 3. That’s one of the reasons why so many patients have the wrong diagnosis – which is both costly in terms of medical bills, time, and pain and suffering.
There is a risk in asking this question – you don’t want to be over-tested for conditions that you are unlikely to have, of course. But I maintain that the cost/risk of living with the wrong diagnosis far exceeds the risk of additional testing to confirm the correct diagnosis. So my advice to patients is to keep this very important question in mind when you see your doctor for a new concern.
In addition to asking this question of your doctor, you can also ask it during a second opinion meeting with another physician. The good news is that these days you don’t even need to get a second opinion in person. I myself have been working with an online second-opinion service called eDocAmerica for several years. Those who sign up for the service can pick the brains of board-certified U.S. physicians on any subject, 24-7 via email (and in some states via phone). The cost is extraordinarily reasonable when provided by employers, and winds up being about one or two dollars per member per month.
If you have a complicated disease or condition (such as cancer) where experts may not all agree on the best treatment plan, a company called Best Doctors offers detailed chart reviews and second opinions from top specialists at academic centers. Again, this service is quite affordable and reasonable if the cost is spread among a group. Employers are able to pay a small fee per employee per month to enroll the entire company in the service.
So why don’t all employers offer these benefits? I suspect that part of the reason is lack of awareness that second opinion services exist, and the other part is tepid demand on the part of employees. So if you’d like to make sure that you’re not one of the five people who have the wrong diagnosis, why not raise the question with your HR department? Enrolling as an individual is also an option, and still as inexpensive as about thirty dollars a month.
My bottom line: make sure you ask your doctor the magic question at least once for every new concern that you have. And if you’re too shy to do it, or your doctor’s answer seems too short, then get a second opinion online or in person.
This one little question could save your life.
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A "Medical Service Provider"
As I sat in my orthopedist’s exam room, the discussion quickly turned from my chief complaint to his: “I don’t know why I’m doing this anymore,” he said. “Medicine is just not what it used to be, and I don’t enjoy my work anymore. The bureaucracy and regulations are bad enough, but what really gets me is the hostility. My patients are chronically angry and mean. The only comfort I get is from talking to other doctors. Because they all feel the same way.”
Perhaps this sentiment strikes you as the spoiled musings of a physician who is lamenting his demotion from “god” to “man” – reflecting the fundamental change in the public perception of doctors that has occurred over the past ~50 years. Or maybe you wonder if this surgeon’s patients are mean because he is a bad doctor, or isn’t respectful of their time? Maybe he deserves the hostility?
I’ve found this particular surgeon to be humble, thoughtful, and thorough. He is genuinely caring and a proponent of conservative measures, truly eager to avoid surgical procedures when possible. He is exactly what one would hope for in a physician, and yet he is utterly demoralized. Not because of the hours of daily documentation drudgery required by health insurance and government regulators, but because the very souls he has been fighting to serve have now turned on him. Their attitudes are captured in social media feeds on every major health outlet:
Doctors? I no longer afford that kind of respect: I call them “medical services providers.” They and their families and the medical cabal created this mess when they got control of med schools so that the wealth of a nation would remain in the hands of a few medical elites and their families. The very notion that doctors are smarter, more productive, more anything than others is ludicrous. They are among the worst sluff-offs of our society, yet the richest at the same time. It is an unreal world they have created themselves and they are now watching the natural outcome of such a false system.
The very best physicians have always been motivated primarily by the satisfaction of making a difference in their patients’ lives. That drive to “help others” is what makes us believe that all the sacrifices are worth it – the years of training, the educational debt, the lack of sleep, the separation from family, the delay (and sometimes denial) of becoming a parent, the daily grind of administrative burden, the unspeakable emotional toll that death and disease take on your heart… All of that is offset by the joy of changing and saving lives. But when that joy is taken from you, what remains is despondency and burn out.
What patients need to realize is that they have been (and still are) the primary motivator of physician job satisfaction. Patients have the power to demoralize us like no one else – and they need to take that power very seriously. Because if negative attitudes prevail, and hostility spreads like a cancer in our broken system, the most caring among us will be the first to withdraw.
And in the end all that will be left is “medical service providers.”
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I used to be a big believer in the transformative power of digital data in medicine. In fact, I devoted the past decade of my life to assisting the “movement” towards better record keeping and shared data. It seemed intuitive that breaking down the information silos in healthcare would be the first logical step in establishing price transparency, promoting evidence-based practices, and empowering patients to become more engaged in their care decisions. Unfortunately I was very wrong.
Having now worked with a multitude of electronic medical records systems at hospitals around the country, one thing is certain: they are doing more harm than good. I’m not sure that this will change “once we get the bugs out” because the fundamental flaw is that electronic medical records require data entry and intelligent curation of information, and that becomes an enormous time-suck for physicians. It forces us away from human interaction, thus reducing our patients’ chances of getting a correct diagnosis and sensible treatment plan.
How bad is it? The reality on the ground is that most hospitals are struggling enormously with EMR implementation. There are large gaps in the technology’s ability to handle information transfer, resulting in increased costs in the hundreds of millions of dollars per small hospital system, not to mention the tragically hilarious errors that are introduced into patient records at break neck pace.
At one hospital, the process for discharging a patient requires that the physician type all the discharge summary information into the EMR and then read it into a dictation system so that it can be transcribed by a team in India (cheaper than US transcription service) and returned to the hospital in another part of the EMR. The physician then needs to go into the new document and remove all the typos and errant formatting so that it resembles their original discharge summary note. In one of my recent notes the Indian transcriptionist misheard my word for “hydrocephalus” and simply entered “syphilis” as the patient’s chief diagnosis. If I hadn’t caught the error with a thorough reading of my reformatted note, who knows how long this inaccurate diagnosis would have followed the poor patient throughout her lifetime of hospital care?
Another hospital has an entire wing of its main building devoted to an IT team. I accidentally discovered their “Star Trek” facility on my way to radiology. Situated in a dark room surrounded by enough flat panel monitors to put a national cable network to shame, about 40 young tech support engineers were furiously working to keep the EMR from crashing on a daily basis – an event which halts all order processing from the ER to the ICU. Ominous reports of the EMR’s instability were piped over the entire hospital PA system, warning staff when they could expect screen freezes and data entry blockages. Doctors and nurses scurried to enter their orders and complete documentation during pauses in the network overhaul. It was like a scene from a futuristic movie where humans are harnessed for work by a centralized computer nexus.
At yet another hospital, EMR-required data entry fields regularly interrupt patient throughput. For example, a patient could not be given their discharge prescriptions without the physician indicating (in the EMR) whether each of them is a tablet or a capsule. As patients and their family members stand by the nursing desk, eager to be discharged home, their physician is furiously reviewing their OTC laxative prescriptions trying to click the correct box so that the computer will allow the transfer of the entire prescription list to the designated pharmacy. When I asked about the insanity of this practice, a helpful IT hospital specialist explained that the “capsule vs tablet” field was required by Allscripts in order to meet interoperability requirements with our hospital’s EMR. This one field requirement probably resulted in hundreds of extra hours of physician time per day throughout the hospital system, without any enhancement in patient care or safety.
For those of you EMR evangelists in Washington, I’d encourage you to take a long, cold look at what’s happening to healthcare on the ground because of these digital data initiatives. My initial enthusiasm has turned to exasperation and near despondency as I spend my days as a copy editor for an Indian transcription service, trying to prevent patients from being labeled as syphilitics while worrying about whether or not the medicine they’re taking is classified as a tablet or a capsule in a system where I may not be able to enter any orders at all if the central tech command is fixing software instability in the Star Trek room.
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As I travel around the country, working in the trenches of various hospitals, I’ve been struck by the number of errors made by physicians and nurses whose administrative burden distracts them from patient care. The clinicians who make the errors are intelligent and competent – and they feel badly when an error is made. However, the volume of tasks required of them in a day (many of which are designed to fulfill an administrative “patient safety” or “quality enhancement” process) makes it impossible for them to complete any task in a comprehensive and thoughtful manner. In the end, administrators’ responses to increased error frequency is to increase error tracking and demand further documentation that leads to less time with patients and more errors overall. It’s a vicious cycle that people aren’t talking about enough.
As I receive patient admissions from various referral hospitals, I rarely find a comprehensive discharge summary or full history and physical exam document that provides an accurate and complete account of the patient’s health status. Most of the documentation is poorly synthesized, scattered throughout reams of EMR-generated duplicative and irrelevant minutiae. Interpreting and sifting through this electronic data adds hours to my work day. Most physicians don’t bother to sift – which is why important information is missed in the mad dash to treat more patients per day than can be done safely and thoroughly.
I have personally witnessed many critical misdiagnoses caused by sloppy and rushed medical evaluations. I have had to transfer patients back to their originating surgical hospitals (at some of America’s top academic centers) for further work up and treatment, and have uncovered everything from cancer to brain disorders to medication errors for patients who had been evaluated and treated by many other specialists before me. No one seems to have the time to take a long hard look at these patients, and so they end up undergoing knee-jerk treatments for partially thought through diagnoses. The quality of medical care in which I’ve been engaged (over the past 20 years) has taken a dramatic turn for the worse because of volume overload (fueled by diminishing reimbursement) in the setting of excessive administrative and documentation requirements.
To use an analogy – The solution to the healthcare cost crisis is not to increase the speed of the assembly line belt when our physicians and nurses are already dropping items on the floor. First, stop asking them to step away from the belt to do other things. Second, put a cap on belt speed. Third, insure that you have sufficient staff to handle the volume of “product” on the belt, and support them with post-belt packaging and procedures that will prevent back up.
What we require most in healthcare is time to process our thoughts and engage in information synthesis. We must give physicians the time they need to complete a full, comprehensive, evaluation of each patient at regular intervals. We need nurses to be freed from desk clerk and safety documentation activities to actually inspect and manage their patients and alert physicians to new information.
Until hospitals and administrators recognize that more data does not result in better care, and that intelligent information synthesis (which requires clinician time, not computer algorithms) is the foundation of error prevention, I do not foresee a bright future for patients in this manic assembly line of a healthcare system.
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On Assignment In California Vineyard
This post is the continuation of my personal thoughts and reflections about what it’s like to work as a Locum Tenens (traveling temp) physician.
Q: Where are the most favorable locums jobs?
This is an interesting question and depends a little bit upon personal taste and priorities. While most locums physicians choose their work based on location (see this nice survey of locum priorities), more experienced locums docs choose their work based on circumstance. What I mean is that it’s more important WHY the hospital needs you, than where the hospital is physically located. It only takes one really bad assignment to learn that lesson the hard way. For instance, if a hospital is recruiting a locum tenens physician because the place is so bad that no one will stay in the job, then I can pretty much guarantee that it won’t matter how nice the city/town/countryside is nearby, you will not enjoy your time there.
Positive prognostic indicators for a good locums assignment include:
1. The person you’re filling in for needs vacation coverage or are on maternity/paternity leave. They are happy with their job and are eager to come back.
2. The hospital is undergoing a growth phase and needs help staffing new wings/wards.
3. The hospital is operating in the black but happens to be in a rural area where it is challenging to find enough physicians to meet the patient needs.
1. The medical director/staff physician “doesn’t have time” to talk to you about the assignment before you commit to doing it.
2. There is more than a second-long pause when you ask the medical director why he/she would want to work there as a locums.
3. The person you’re filling in for was fired due to incompetence or negligence.
4. The person you’re filling in for is on the verge of a nervous break down from overwork, and a locums agency was called in to prevent implosion/explosion type scenarios.
5. There have been multiple staff (nursing usually) strikes at the hospital in the past 6 months.
7. The group with whom you would work is not culturally diverse – and you can imagine having difficulty gaining acceptance by them.
In my experience, you can enjoy living anywhere temporarily if the people and circumstances are pleasant. A nice post-work dinner/coffee with friendly, competent staff – even in a “backwater” setting – trumps a solo trip to a high end, big city restaurant when you are emotionally and mentally exhausted by the misery of a bad hospital. Trust me on this.
As one locums hospitalist put it: “Generally I’ve found the rural hospitals to be the nicest, especially in the midwest. But I’m never going back to South Dakota in the winter.”
Q: How can I negotiate the best salary?
First of all, you need to know that this is a negotiation. When I first started, I just assumed the salary I was offered required a binary response: “Yes, I’ll accept the position,” or “No I’ll keep looking for other opportunities.” That’s why I’m a physician and not a business woman, I guess! Just ask my husband.
Anyway, after a few experiences of getting paid a lower salary than my peers at the same job, I realized the error of my ways. In many cases you can lobby for up to 25% higher pay rate, so you should keep that in mind. In summary, here is where the salary “wiggle room” is:
1. How much overhead your agency charges. Remember the “platinum” agency I referred to in my last post? If you’re working with one of the agencies that is known to be “expensive” then they have more money that they could share with you. If you’re working with a budget agency who competes based on low overhead fees (such as 20% above your base salary rate), then you’ll never get more than $5-10 more/hour from them.
2. If you have a good track record. Once you’ve proven yourself to be an excellent physician, well-liked by the hospital staff where you’ve been assigned, the agency is going to want to keep sending you to new assignments because you’re more likely to get requests to return and will stay longer at each gig. The agency (and the recruiters) make money based on how many hours you bill, so they’d rather send a “sure thing” to a new client than an unknown. They will be more likely to up your salary to seal the deal, knowing they’ll probably get more hours with you in the long run.
3. How desperate the client/hospital is. This is sad to say, but desperate clients will pay higher rates to fill a need. If you’re being offered an unusually high salary for a certain assignment, don’t rejoice, worry (see notes above about “red flags.”)
4. If you bundle. Some enterprising primary care locums docs get together to negotiate group rates. That means, if you have a friend or two who can agree to travel together to a particular place, the agency can pay a higher salary to each of you because they’re getting a larger volume of hours overall. This works really well for internal medicine locums, for example, where hospitals often need multiple docs at a time. It’s actually a brilliant plan, because the people who do it are already sympatico, they have similar work ethics, can share call, sign out to each other, have built in friends to enjoy after work adventures, and arrive as a well-oiled machine. I think this is probably the future of primary care locums. However, if you’re like me (a specialist in a small field) there’s no way to bundle because no hospital ever needs more than one of you at a time.
5. If you take longer assignments. This stands to reason. If you are going to be working for months (rather than weeks) at a certain hospital, then you have more room to negotiate a larger hourly rate based on the volume principle I described above.
Q: How do locums agencies decide how to match you with a given job opportunity?
Based on my experience, the agencies’ order of priorities for matching physicians with clients are:
1. Whoever is available and answers their phone first. The Locums world is very dog-eat-dog for the agencies. It’s a daily race to see who can present physicians to fill needs the fastest. Hospitals are looking for the lowest cost solution to their staffing gaps, and will shop multiple agencies for the same positions at once. The agency who brings the first acceptable C.V.s wins the work. Sometimes when there is controversy over which agency gets the job, the client has to review email time/date stamps to verify which came first. Sometimes it’s a matter of minutes. So… if your recruiter’s voice sounds a little tense, you’ll understand what’s going on in his/her world. And if you’re hungry for locums work, be sure to respond promptly for consideration. That being said, once you’ve established a track record with a few agencies, you’ll have turn away business year-round (especially in primary care).
2. Client preference. Once your C.V. has been presented to the client, they will choose their preferred candidate (if there is more than one option). Usually, they are looking for someone local or whomever will generate the lowest travel expenses. I wish that clients delved a little deeper than that, but my experience is that cost trumps coolness for them most of the time. And when I say “coolness” I mean – wouldn’t you rather have a candidate who writes well, has an unusual background (say – someone who has built medical websites and has been a food critic and cartoonist? Ahem?) than just another chem major straight out of IM residency? Apparently most would say no thanks. Just give me the cheaper one.
3. If they know and like you. Let’s say there are two equally qualified physicians for the same position already screened and signed up for work at a certain agency. If one of you has a track record of being flexible and easy to work with (rather than a demanding, entitled brat – like a few doctors you may know) then the recruiter will put the “nice” person’s CV on top and market you more strongly to the client. Why? Because she doesn’t want to receive whiny phone calls every other day during your assignment about how you don’t like the hospital food. The recruiters have “quality of life” issues too. If you’re lucky and you develop a good, long term relationship with your recruiter, they’ll probably even do YOU a favor and give you a head’s up about upcoming opportunities at the “good” hospitals. And we all know what that means.
4. Whoever will take the lowest hourly rate. In the end, it’s still all about the Benjamins so if there are 2 equally qualified physicians who are similarly “non whiny” then if one will work more days or at a lower rate, then they are more likely to get the job (due to recruiter influence on client preference). But given the large number of positions and the small number of locums to choose from, this game is 80% about who’s available first. Then the rest of the variables follow.
Q: What is the licensing and credentialing process like? How do I make it easier?
The state licensing and hospital credentialing is the most painful administrative part of the whole locum tenens assignment process. If you’re considering an opportunity in say, North Dakota, then you’ll need to get a state license there (Unless you already have one?) as well as passing the scrutiny of the rural hospital credentialing committee where you’ll be working. And yes, everyone seems to want original copies of the intern year you did 15 years ago at the hospital that has since closed. You feel my pain?
There is good news and bad news about this. The good news is that the Locums agencies have hired staff to complete the medical license and credentialing paperwork for you. That is part of the “value” they bring to you as an agency. The bad news is that some of their staff can’t spell. Or they get the chronological order of your residency/fellowship years wrong, etc. thus generating MORE work for you in the long run, correcting errors rather than filling in blanks.
The middle road is to fill out the paperwork correctly yourself the first time, and then offer copies to the agency staff for future licensure/credentialing. They can transcribe better than synthesize, so this seems to be the best way to go, IMO.
Hospital credentialing is nuanced, and depends on the culture of the local hospital in terms of how many references they require and how much documentation detail they request. Some hospitals are swift and lean, others comb through your background as if you are a likely convicted felon.
That being said, one thing is certain – if you plan to work several different locums assignments your referrers are going to be nagged TO DEATH. Everyone needs 2-3 professional references who will be called/contacted mercilessly, first by the Locums agency to make sure you’re not a “problem person” (as described in Part 1), then by the hospital who is considering hiring you (not that they’ve committed yet), then by the credentialing committee (if you pass approval in the first round), then by the state licensing body. So for every potential locums assignment, your professional reference will likely be contacted 4 times, and asked to vouch for you verbally or on paper/via fax. Imagine how many assignments you’ll do in a year and the math gets pretty scary. Be sure your references are ok with all this attention… and give them fair warning. If you can, spread the pain and broaden your reference base.
Q. What advice do you have for Locums agencies?
1. Physicians talk. Whatever sneaky deal-making you’re doing (such as paying people different rates for the same gig or getting a 50% premium at a desperate hospital and then not sharing it with us in salary upgrade) is going to come to light at some point, so keep your nose clean. Please be honest about problem hospitals and work conditions. I know that clients mislead you about work conditions and expectations so as to lure locums to their facility – but try to go the extra mile to figure out in advance if the doctors are really going to be asked to see 16 patients a day or 26 patients a day. Because if we get to the site and we’re being abused and overworked, we associate the negative experience with the agency that put us there. Then you try to wheedle and cajole us into finishing the assignment based on the contract we signed so you can make your cut. Meanwhile we’re putting our careers in danger because we can’t do a thorough job and might miss something important. Not good for physician retention. Better yet, just say no to crisis clients. The money isn’t worth it.
2. Treat us right and you’ll make more money in the long run. I know you’re under pressure to save money on our travel and hotels, but you also have some flexibility in the room rate that you’ll consider. Put us in a nicer hotel for a few bucks extra per night and the whole experience will seem a little brighter. Put us on the preferred rental car program so we don’t have to wait for 2 hours in a rental car line after a full day of cross-country travel. Upgrade us to a full size car rather than the beige Corolla we have to live in for months. These little things end up costing you only a few hours of our total billing, but make your agency our go-to employer.
3. Pay us on time. It’s so simple, and costs you nothing. If an agency takes 3-4 months to pay me for an assignment, and then the billing is inaccurate (missing hours)… I’m going to choose another agency next time. Your value to me is partly in the ease of payment – a direct deposit a week from when I fax my time sheets sends me the message that you have your act together and are respectful of my time. Making me sift through miss-billed records from half a year ago is just not acceptable.
4. Try to understand why we whine. Locums work is not easy. We are often separated from our friends and family, in an unfamiliar setting, learning complicated hospital processes with patients who are sick and dying. We don’t know if the nurses or consultants are competent while we ourselves are under intense scrutiny until the staff gets to know us. We have to build trust, navigate complicated electronic medical records systems, satisfy hospital coding and billing demands, and keep a ward full of patients (with their team of specialists whom we’ve yet to meet) on the path to healing. All this, and we are legally responsible for everything that goes on in the lives of those under our care. When we get home to our Days Inn at the end of our 15 hour shift in our beige Toyota Corolla to find their exercise equipment broken and the lobby overrun with monster-truck rally participants, we may be a tad whiny. Please don’t think ill of us for that. Just do what you can to help us feel better. We, and our patients, will thank you.
Dr. Jones is available on a consulting basis through Better Health LLC. She may be reached at email@example.com